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MEDICAL RECORD. 



A JVeekly yoiirnal of Medicine and Surgery 



EDITED BY 

THOMAS L. STEDMAN, A.M., M.D. 



IrJolumc Q>Q>. 

JULY 2, 1904— DECEMBER 31, 1904 




NEW YORK 
WILLIAM WOOD AND COMPANY 

1904 



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ll 



COPYRIGHT, 1904. 
By WILLIAM WOOD AND COMPANY. 



Medical Record 

A Weekly Journal of Medicine and Surgery 



Vol. 66, No. I. 
Whole No. 1756. 



New York, July 2, 1904. 



$5.00 Per Annum. 
Single Copies, lOc. 



CPrtginal Arttrba. 



THE DISTIN"CTIVE CHARACTER OF THE 
TEMPERATURE CURVE OF MEASLES AND 
OF SCARLET FEVER; AXD THE TREAT- 
MENT OF HYPERPYREXIA IN THESE 
DISEASES BY BATHS OF INCREASING 
TEMPERATURE.* 

Bv HENRY W. BERG. M.D.. 

NEW YORK. 
VISITING PHYSICl.^N TO THE WILL.\RD PARKER AND RIVERSIDE HOSPITALS; 
ADJUNCT PHYSICIAN TO MOUNT SINAI HOSPITAL; INSTRUCTOR IN IN- 
FECTIOUS DISEASES. COLUMBIA UNIVERSITY. 

The clinical observation of measles and scarlet 
fever in hospital and private practice has led me to 
the conclusion that the temperature curve in these 
two acute infectious diseases is as characteristic 
and distinctive for each of them as are the respective 
curves of typhoid, typhus, and smallpox. I am 
well aware that this is not the view of the vast 
majority of writers on measles and scarlet fever, 
and it becomes all the more important that each 
of us who sees much of these diseases in a system- 
atic way should add his quota of observation to 
the recognition of the normal course of the tem- 
perature curve in these extremely common affec- 
tions. 

The' temperature curve of the acute infectious 
diseases is divisible into three stages: (i) That of 
accession, including the beginning and rise of the 
temperature to its maximum; (2) the fastigium 
or stage during which the temperature continues 
at its height before the positive decline has set in, 
which forms (3) the stage of defervescence. The 
first stage may be an acute steep rise to a high 
temperature in the course of a few hours, or a 
gradual rise, continuing for days before the fas- 
tigium or period of maintenance is attained. The 
second stage, or fastigium, also varies in duration 
in different diseases. In some the temperature is 
maintained for some days, in others the fastigium 
is scarcely attained before the third stage of the 
temperature, or that of defervescence, begins. Of 
the third stage, there are two types. When -t 
declines rapidly, as in pneumonia, the temperature 
is said to resolve by crisis; when it declines gradu- 
ally by a slow diurnal descending staircase move- 
ment, the resolution is by lysis. 

Before discussing the temperature curve of the 
two diseases to which these observations are limited, 
I wish to object to the customary description of 
the symptoms of measles and scarlet fever under 
the head of the stage of invasion or prodromal stage, 
the stage of eruption, and the stage of desquamation. 
The stage of invasion or prodromal stage corres- 
ponds with the appearance of the enanthematic 
eruption upon the mucous membranes, those of the 
conjunctiva, the nasal fossae, buccal cavity and inside 
of the lips and cheeks in measles, and the pharynx, 
tonsils, and tongue in scarlet fever. This stage is 
as much a part of the eruptive stage as is the ex- 
anthema itself. The so-called prodromal tempera- 

*Read before the New York Academy of Medicine, May 
19. i9°4- 



ture is the temperature of the enanthematic stage 
of the eruption-. The conception of the desquama- 
tive stage as synonymous with that of defervescence 
is also faulty, in that it would give the impression 
that desquamation begins with defervescence or 
disappearance of the eruption, which is rareh' true 
even in measles, and is never true in scarlet fever. 
Every one who sees much of the latter disease 
knows that, as far as the skin lesion of this disease 
is concerned, there is in a large proportion of cases 
a period of three to eight days or more after the 
eruption has entirely disappeared and the skin has 
become normal to the eye and touch before des- 
quamation begins. During this period the most 
expert clinician could not, in many cases, affirm 
from the presence of any positive symptoms that 
the patient had suffered from scarlet fever, and 
when the history points to that disease he awaits 
the appearance of the characteristic desquamation. 
While this is not true of measles, in which the skin 
does not return to its normal color or appearance 
until after desquamation is completed, yet even 
here the fading of the characteristic erupt'on is not, 
as a rule, immediately followed by desquamation, 
but there is generally a period of some days before 
desquamation sets in. If these diseases must be 
described clinically under the head of stages, it 
would be more logical and true to write of them as 
(i) the eruptive stage, including the enanthematic 
and exan thematic periods; (2) the stage of defer- 
vescence; (3) the stage of desquamation. 

The pyrexia of measles and scarlet fever, due to 
the respective specific infectious cause of these dis- 
eases occurs during the eruptive stage as thus de- 
fined and the stage of defervescence. By that I 
do not mean that the rise and fall of temperature 
that occurs during these stages of all cases of measles 
and scarlet fever is due to the specific virus of 
these diseases, emphatically not; for very many 
suffer during the earliest as well as the latest 
stage from a variety of complications and mixed 
infections, each of which causes modifications and 
deviations from the temperature curves character- 
istic of measles and scarlet fever when these diseases 
are uncomplicated. What is meant is that the 
characteristic temperature curve of measles as well 
as the characteristic temperature curve of scarlet 
fever covers the stage of eruption and the stage of 
defervescence. 

Let me then describe the characteristic tempera- 
ture curve of an uncomplicated case of measles in 
which there is pyrexia. During the enanthematic 
period of the eruptive stage the pyrexia is moderate ; 
it rises toward night, it declines about a degree 
toward morning. It lasts for from two to five davs. 
There is a slight increment of pj^rexia every even- 
ing as compared with that of the evening before. 
There is, however, a sharp decline, sometimes to 
within a degree of the normal, on the morning of 
the day when the skin eruption (face) is to appear. 
Synchronous with the appearance of the exanthema, 
the pyrexia becomes greater and the temperature 
rises rapidly, generally to a higher point than any 



MEDICAL RECORD. 



[July 2, 1904 



reached during the enanthematic period of the one or two degrees by morning of the next day. 

eruptive stage. On the first day of the skin erup- During this day the eruption becomes complete, 

tion, with the appearance of the exanthema on the covering the legs and dorsum of the feet. The 

face, the temperature is apt to be a degree higher temperature again rises toward night, but not as 
than the highest figure of the enanthematic stage. 
From this figure there is a decline of about a degree 





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Chart 



Schematic Measles; 1. enanthema; j, e.xanthema. 



by the following morning. During this second 
day the eruption covers the neck, chest, arms, 
and shoulders, and toward night the pyrexia is 
about a degree higher than that of the evening 
before; there is a slight decline toward next mom- 



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Chart a. Measles, Jos. E, : i, enanthema; 2. exanthema. 

ing. On that day the eruption covers the ab- 
domen, back, and thighs, and the temperature rises 
by evening a degree or a degree and a half higher 
than the evening preceding. This is the ma.ximum 
height during the whole course of the essential 
temperature curve of the disease. It again falls 









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Chart 3. Measles. Defervescence. Oukio R. 

high as the night before. During the night and 
following morning there is a decline or defer\'escence, 
abrupt and sharji, either down to the normal or 



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Chart 4. Measles, Defervescence. Jos. F. 

almost normal, within twelve to twenty-four hours, 
or the abrupt decline may be interrupted at about 
midway by a slight evening rise and then an abrupt 



July 2, 1904] 



MEDICAL RECORD. 



decline to the normal by the following morning. 
This is schematically shown in chart i and in chart 
2. the latter a complete uncomplicated measles 
curve from a case in private practice. If I were 
asked to indicate the most characteristic phe- 





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Chart 5. Measles, .\niue G. 

nomenon in the typical measles tempera ture curve- 
I shoiild say that it is this tendencj' to resolution 
or defervescence of the pyrexia by crisis. In this 
respect it differs positively and absolutely from 
the temperature curve of scar- 
let fever, in which, as I shall 
presently show, the resolution 
of the pyrexia takes place by 
lysis. I J I' 

Frequently in severe Teases 
of uncomplicated measles the 
writer has been able to predict 
that the temperature would 
fall to the normal on a certain 
given day, although on the 
day previous, at the time of 
the statement, the tempera- 
ture was still at a very high 
and even alarming figure. This 
prognosis rested upon the 
absence of any complication 
in that particular case, and my 
absolute reliance on the posi- 
tive fact that the pyrexia of 
uncomplicated measles always 
undergoes a resolution by crisis, 
as indicated above. The tem- 
perature curves taken from the 
histories of normal uncompli- 
cated measles cases demon- 
strate graphically what I have 
attempted to describe at length. 

(Charts 2, 3, 4, 5, and 10.) AH but chart 2 are 
temperature curves from cases in the Riverside 
Hospital. 

Scarlet fever, when uncomplicated, has a much 
simpler temperature curve than measles. Never- 



theless this curve is characteristic of this disease 
During the development of the enanthema syn- 
chronous with the initial vomiting and sore throat 
the temperature reaches a ver\' high degree, fre- 
quently the highest point of the temperature curve. 
The enanthematic eruption is ver\- rapidly followed 
by the exanthema, sometimes within six or eight 
hours, generally within one or at most two daj's. 
During this time the temperature is maintained 
at its height, suffering only the usual decline of a 
degree or a degree and a half toward morning, to 
rise again at night. If the skin eruption is delayed 
a slight drop in temperature precedes it. (Chart 7, 
from a case in private practice.) With the appear- 
ance of the exanthema the temperature is main- 
tained at its height for three or four days more, 
while the eruption covers the body. The first 
slight decline is noticed when the eruption has 
reached the lower part of the legs and dorsum of 
feet, about the third or fourth day. This decline is 
slight, not more than two degrees, followed by a 
slight rise at night, but not as high as the tempera- 
ture of the previous night, next morning again to 
decline to a degree or a degree and a half lower than 
the morning before, and so on, the teniperature 
curve descending by steps ver\- much after the man- 
ner of the typhoid curve until the normal is reached 
after five to eight days. In this disease the def- 
ervescence of the pyrexia is by lysis. This cur^'e 
is schematically shown in chart 6, while chart 7 
shows a curve from a case of uncomplicated scarlet 
fever observed from its very beginning to its end. 
The temperature curve of measles as compared 
with that of scarlet fever shows the following points 
of difference: In measles the accession of the fever 
is gradual (shown in charts e, 8, and 9), the fas- 
tigium limited (charts i and 2), and the defer- 
vescence by crisis (charts i, 2, 3, 4, and 5). In 
scarlet fever the accession is acute (charts 6 and 7) 
and sudden, the fastigium lasts through almost the 
whole of the eruptive stage (charts 6 and 7), and 
the defervescence is by lysis (charts 6, 7, 11, 12, 





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Chart 6. Schematic Scarlet Fever; 1. enanthema; 2, e.xanthema. 



13, 14, 15, and 16).* I have spoken only of the un- 
complicated measles and scarlet fever temperature 
curve, carefully abstaining from giving any abso- 

(*Charts 10 to 16 are from cases in the Riverside Hos- 
pital, scarlet-fever service.) 



4 



.MEDICAL RECORD. 



[July 



1904 



lute temperature figures. For the general trend 
of a temperature curve that is distinctive and 
characteristic of a disease must be true, whether 
the p3-rexia be a severe one with high temperature, 
or mild with very low temperature. 

There are said to be also cases of measles and 





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Chart 



Scarlet Fever; i, enanthema; 2, exanthema 



scarlet fever which run their course without any 
temperature. I have never seen such a case in hos- 
pital or private practice. I have frequently seen 
cases in which the fever has been verj- slight, but 
recognizable by rectal thermometric ob.servations. 
I have certainly heard from mothers whose children 
showed b}' a characteristic desquamation and other 
sj^mptoms that scarlatina had run its course in the 
little patient, and that there had been no fever 
accompanying the rash, but s\jch statements resting 
solely upon nonprofessional observation and fre- 
quently lack of observation can hardly be taken 
as the basis for clinical data. 

Of great importance is the fact that eminent au- 
thorities differ as to whether the temperature 
curves of measles and of scarlet fever are respectively 
distinctive of these diseases. Scarcely any two 
works on medicine agree as to the temperature 
curves of either measles or scarlet fever. Thus 
Wunderlich (Eigenwarme in Krankheiten, 1870), 
whose thermometric studies are classical, considers 
the measles curve absolutely distinctive, and that 
of scarlet fever also, under certain limitations. The 
curve for scarlet fever, which I have found in mv 
experience differs from that of Wunderlich in many 
particulars, and my impression does not confirm 
the views of Wunderlich with regard to the measles 
curve in many rcsiJects, but the critical deferves- 
cence in measles and the defervescence by Ivsis in 
scarlet fever Wunderlich emphatically recognizes. 
Indeed, this shrewd obser^'cr makes this broad 
statement: 

"The course of the temperature must be individual 
and characteristic in each separate infectious dis- 
ease ; each must present its typical curve, and if we 
fail to recognize it, the fault certainly lies with us." 
(Uber einige Verhaltnisse des Fieberverlaufes bei 
Masem, Archiv der Hcilkmide, 1863, p. 332.) 

Just as we commonly accept as characteristic of 
smallpox, its well-known, peculiar temperature 
curve, and as characteristic of typhoid and typhus 
fever, the recognized curve of the pyrexia in these 



diseases respectively; to this extent at least, is the 
fever curve in measles and scarlet fever distinctive. 
The objectors to this view, prominent among whom 
are Thomas and also von Jiirgensen, seem to expect 
more uniformity in the course of the fever of 
measles and scarlet fever as a sine qua noti, for con- 
sidering them distinctive, than 
they do from the curve of the 
fever in typhoid and typhus, 
which they agree are eminently 
distinctive. And yet variations 
from the typical fever course in 
measles and scarlet fever can be 
accounted for more easily and 
are far less numerous than the 
variations from the typical 
course in typhus and typhoid. 
One important reason why phy- 
sicians do not recognize how 
typical are the fever curves of 
measles and scarlet fever, lies 
in the fact that pyrexia in these 
diseases, when uncomplicated, is 
much shorter in duration than 
that of typhoid and typhus. 
Then, too, complications of an 
inflammatory nature frequently 
mask the characteristic curve in 
scarlet fever and measles. Es- 
pecially is this true at the period 
of defervescence, when, in an un- 
complicated case, the fever would 
def ervesce by crisis or pseudocrisis 
in measles, and by lysis in scarlet 
fever. Then, too, measles and scarlet fever can be 
observed in numbers sufficient to enable one to 
make deductions as to the fever curve only in infec- 
tious disease hospitals which are few in number; 





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Ch.\rt J 



Measles, end of enanthema and beginning of exanthema. 
Louis L. 



while of typhoid every general hospital furnishes 
sufficient material. Even in infectious-disease hos- 
pitals the cases come in too late for frequent obser- 
vation of the first two, or even three, days of the 
curve. I have been compelled to study the behavior 



July 2, 1904] 



MEDICAL RECORD. 



of the fever curve in the first days of the disease, 
in ni)- private practice. 

I present some curves of the earlier days of two 
measles cases which I owe to the courtesy of Dr. 
M. Gershel. Physician to the Hebrew Sheltering 
Guardian Society (charts 8 and 9). 

I have sought to explain the fever curve of 
measles and of scarlet fever. In both of these dis- 





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On a similar basis can be explained the rise in 
temperature with the appearance of the eruption on 
the face; the further rise on the following day as 
the eruption covers the chest; the rise to the 
maximum of the curve as the eruption spreads over 
the largest area on the third day of the exanthema, 
when the eruption covers the abdomen, trunk, and 
thighs; the decline as these surfaces are covered, 
f'^llowed by a rise, to a lower plane, however, with 
the appearance of the rash on the lower legs and 
dorsum of the feet, owing to the fact that the 
cxtaneous surface involved is far less in extent than 
that covered on the day previous; and, finally, the 
rapid decline by crisis to the normal, due to the fact 
that the inflammatory disturbance in the cutaneous 
surface has run its course. All of these changes can 
be explained by taking these two causative factors 
of the pyrexia into consideration. 

Nor is it essent'al to believe that with the disap- 
pearance of the fever, the toxic element should have 
been entirely extruded, provided a sufficiently large 
share of it has been neutralized and excreted by 
the skin and mucous membranes, so that it is no 
longer necessary for the body cells to continue the 
excess of chemical and biological activities of which 
the pyrexia was a manifestation and which pre- 
served the cells in their contest against the 
activities and products of the hacteria of which 
the infection consists. _ 

In scarlet fever the toxic agent plays a more im- 
portant role in the production of the pyrexia than 
does the inflammation of the skin or mucous mem- 
branes; nevertheless, the latter, as in measles, has 
its effect, as is well shown in cases of scarlet fever 
in which the enanthema is not followed within a few 
hours by the exanthema on the shoulders and face 



Ch.\rt 9. Measles, showing cun.*e of exanthematic stage. 
Clara C. 

eases the pyrexia is the combined result of the in- 
fluence of the pathogenic germ and its toxins upon 
the various biological and chemical processes going 
on in the blood and tissues of the body, which are 
heat producing, as one factor, together with the rise 
in temperature produced by the inflammatory 
process going on in the mucous membranes and 
skin, to which the enanthema and exanthema are 
due, as another factor. I believe the latter factor to 
be dependent upon the former, for, in my opinion, 
the eruption in the acute exanthemata is simply a 
conservative inflammatory manifestation on the 
skin and mucous membranes due to their activity in 
helping to excrete from the system the toxic mate- 
rials present in the blood and tissues. The influence 
of the toxaemic element in the production of the 
pyrexia is less in measles than it is in scarlet fever. 
On the other hand, the cutaneous inflammatory 
process involved in the eruption of measles has a 
more important influence on the pyrexia curve than 
the skin lesion of scarlet fever has on the tempera- 
ture curve of that disease. 

Keeping these two causative factors of the pyrexia 
i n viow, let us consider in the light of them the measles 
curve. The first portion of the pj'rexia curve, dur- 
ing the enanthema is moderate even in cases of some 
severity, about 103° F., and is due to the catarrhal 
inflammation of the mucous membranes of the 
•mouth, nose and eyes, plus the effect of the activities 
of the toxic agents. The slight drop in the fever 
before the appearance of the exanthema is due to 
the fact that the acme of the inflammation in these 
mucous membranes has been passed and that causa- 
tive element in the pyrexia is therefore diminished. 





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Ch.^rt io. Measles, Defervescence. John H, 

as is usual, but where such exanthema is delayed 
for two or more days, as is the case in the curve of 
normal scarlet fever shown in chart 7. In such cases 
there is a drop in the high temperature after the 
enanthema has appeared and before the exanthema 
appears (charts 6 and 7). But when the eruption 
becomes manifest the temperature rises to the high 



MEDICAL RECORD. 



[July 



1904 



point which it had attained with the initial tonsillitis 
and pharyngitis and vomiting, and the fastigium 
lasts, as already shown, with a slight increase on the 
third day of the eruption, for reasons similar to those 
spoken of under measles, but otherwise not showing 
the daily increment in the fever due to the involve- 
ment of additional skin areas in the eruption. For, 
in this disease, as I have already said, the local skin 





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Chart 11. Scarlet Fever. Defervescence. 



John McK. 

lesion plays a much less important part in the pro- 
duction of the pyrexia than does the toxtemia. The 
whole clinical picture of scarlet fever supports this 
view; the initial toxic vomiting, the rapid pulse and 
the frequency of toxic complications. This toxic 
element is sufficient to keep up in the body cells 
their fever-producing activities 
even after the eruption has 
reached its height and is sub- 
siding. However, gradually the 
toxic agents are overcome, and 
this slowness is pictured in the 
gradual resolution of the fever 
by lysis ; the temperature , while 
declining daily, does not reach 
the normal until four days 
to a week or more after the 
eruption has run its course. 
(Charts 6 and 7, and other 
defervescent scarlet fever tem- 
perature curves.) 

With this view of the tem- 
perature curve and its patho- 
genesis, it is possible bj' carcfvil 
examinations of the patient 
from day to day to account for 
any positive departure from 
the typical fever curve in 
those suffering from these two 
diseases. Nor is it surprising 
that slight variations occur 
even when there are not de- 
cided complications. These 

two eruptive fevers, for the most part, affect 
children in whom even the normal tempera- 
ture curve of the body in health is readily dis- 
turbed by comparatively unimportant factors, 
and yet so tj'pical are the respective fever curves 
in these two diseases that variations in uncom- 



ful study of each case,' and will serve only to 
prove the rule. Such reliance can one place upon 
the typical character of the curve, in my experience, 
that if a positive variation from the usual cur^'e is 
seen, a complication must be sought for and will 
generally be found. Thus, if the critical drop in the 
temperature curve of a measles case in the defer- 
vescence of the fever has taken place, and a rise in 
temperature follows, it can be 
positively affirmed that there 
is a complication, such as pneu- 
monia, otitis media, meningitis, 
etc., which a careful ex- 
amination of the patient will 
reveal. If the critical resolu- 
tion does not occur, but defer- 
vescence is only partial, the 
fever continuing as the eruption 
is fading, a complication, as a 
cause for the continued fever, 
will be found. Furthermore, if 
the course of the fever is not in 
a general way in accordance 
with the typical curve through- 
out the whole of the eruptive 
stage, and a careful examination 
reveals no complication, I have 
generally found that the criti- 
cal defervescence will not oc- 
cur, and gradually the con- 
cealed complication shows itself. 
In other words, an irregular 
curve will put the careful clin- 
ician upon his metal to dis- 
cover the complication which 
causes the irregularity. In one of my cases an 
inflammatory rheumatism, involving at first only 
the vertebral articulations but later on other joints, 
gave rise to a septic temperature curve in a case of 
measles with a typical enanthematic and exanthe- 
matic eruption. Even the presence of very high 





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Ch.\rt 12. Scarlet Fever, Defervescence. Mary B. 



plicated cases will admit of explanation on care- 



pj'rexia in cases with a normal measles temper- 
ature cur\^e enables him who is familiar with the 
measles curve to predict a critical drop at the proper 
time, especially if a careful physical examination has 
failed to reveal any complicating condition. 

In scarlet fever a knowledge of the normal curve 
will enable the physician and the patient's friends 



July 2, 1904] 



MEDICAL RECORD. 



to look with equanimity upon rather high tem- 
peratures during the fastigium, provided no com- 
plications are found. When, however, in the stage 
of defervescence resolution by lysis has begun, and 
after a day or two is interrupted by a renewed rise 
to the higher figures of the fastigium. then a com- 
plication must be sought for and found, for the 





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Chart 13. Scarlet Fever. Arthur M. 

scarlatinal virus uncomplicated never causes a 
renewed rise of temperature in the stage of defer- 
vescence when lysis is in progress. 

A knowledge of the normal temperature curve of 
scarlet fever will enable us to estimate at its true 
value any serum therapy proposed as a specific for 
the disease. For a specific serum treatment tried 
even in large numbers of cases 
may result, owing to the severity 
of the cases upon which it has 
been tried, in a larger death 
rate than that shown in the 
total mortuarj' statistics of a 
city where the death rate is 
based on all the cases of scarlet 
fever which have been reported, 
both severe and mild. But if 
the serum recommended really 
antagonizes the toxic elements 
of the disease, it must necessarily 
cut short the fever which is also 
dependent upon these toxic 
agencies. I should expect 
such specific serum injections, 
whether of the antitoxic or 
antibacterial type, to produce 
a prompt shortening in the 
duration of the fever of the 
fastigium and a defervescence, 
of the critical type, within 
twelve to twenty-four hours 
after the injection. I have 
accordingly attached no im- 
portance to the antistreptococ- 

cus serum therapy, owing to the fact that in the 
cases in which I have observed the Marmorek 
and Moser serum used, I have failed to see such 
or like influences upon the typical temperature 
curve of scarlet fever, as a sequence of these serum 
injections. A recovery after the use of the serum 
means little, for scarlet fever is cured without serum 
therapy. A change in the curve of the deferves- 



cence from lysis to crisis would mean very much. 
The successful antiserum, when discovered, I am 
sure, will show as one of the important clinical 
changes, a shortening of the fastigium of the fever 
curve and a resolution of the fever by critical drop 
and not by lysis. 

In the course of my remarks I have purposely 
avoided any reference to abso- 
lute high or low temperatures in 
measles and scarlet fever, the 
object of this stud}' being the 
development and recognition of 
the typical character of the un- 
complicated temperature curve 
from day to day, irrespective 
of its absolute height or low- 
ness. I may be permitted, 
however, to speak of the prac- 
tical and important question of 
the treatment of hyperpyrexia 
in these two diseases. I think 
we may assume, for the purposes 
of this paper, that occasionally 
in measles and scarlet fever 
even when uncomplicated, the 
temperature, owing to its extra- 
ordinary height, may require 
therapeutic attention. This, not- 
withstanding the fact that from 
what has been said, our knowl- 
edge of the character of the 
curve enables us to predict its 
duration and probable extent 
as long as no complicating con- 
ditions occur. All the more does the temperature, 
when excessive, require attention in those cases 
in which complications exist; for not only is 
the temperature in some of these cases apt to 
rise to much higher levels, but owing to the 
uncertainty of its duration we must avoid as far as 
possible the evil effects of hyperpyrexia which the 





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Chart 14. Scarlet Fever, Defer\-escence. Rose G. 

patient may have to endure for some time. The 
usual methods for reducing temperature in infectious 
eruptive fevers, employed also in measles and 
scarlet fever, are cold or cool baths, like the Brand 
baths, used in typhoid, cold or cool sponge baths, 
cold pack, and antipyretic drugs. The last, we may 
dismiss with an interdiction. I do not know of any 
of the acute infectious diseases in which these drugs 



8 



MEDICAL RECORD. 



[July 



1904 



are warranted for the reduction of hyperpyrexia. 
The reasons for this are for the most part well kno-wTi 
and we need not enter upon them here. As far as 
the use of the other three methods is concerned, 
baths, sponge baths, and the cold pack, one fact is 
true with reference to all three of these methods of 
reducing hyperpyrexia when applied to measles and 
scarlet fever, and that is that 
no such reduction of tempera- 
ture, either in amplitude or in 
duration, as is obtained from 
these methods in the high tem- 
peratures of other diseases, such j^j 
as typhoid or pneumonia, 
takes place from their use in 
the pyrexia of measles and 
scarlet fever. This is easih^ 
accounted for. In both of 
these eruptive diseases, cold, 
-whether in the shape of baths, 
^sponging or packs, has a 
■different effect upon the skin, 
which is the seat of an ex- 
anthema, from that which it 
has in diseases in which the 
skin is in a normal conditir)n. 
The subcutaneous swelling and 
infiltration which is a part of 
the eruption causes pressure 
upon the cutaneous capillaries 
and their nerves. These capil- 
laries do not undergo the 
primary contraction under the 
influence of cold which occurs 
when cold is applied to healthy 
secondary dilatation which follows the primary in- 
stantaneous contraction where the skin is normal, 
occur in skiii which is the seat of a measles or scarla- 
tinal eruption. There is, therefore, not that inter- 
change of cooled blood from the periphery and 
warm blood from the center which is so necessar\^ 
a condition to the reduction of temperature by cold 



primarily and secondarily. I have referred above 
to the importance of the sweat glands in aiding the 
skin to excrete from the body the toxic materials 
which are the essence of the disease in measles and 
scarlet fever. I even believe that the eruption itself 
is the conser\-ative manifestation of the eliminative 
activity on the port of the skin; so that any method 





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Chart 15 
nor does the 



Scarlet Fever. Defervescence. Sylvester M. 





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Chart i6. Scarlet Fever. Defervescence. Elsie K. 



baths or pack. On the contrary, I have seen these 
agents when applied to a brilliant scarlatina cause 
the red rash to become violet and almost hemor- 
rhagic and spotted in character, owing to stasis of 
the cutaneous circulation. 

For the same reason cold baths and cold packs in 
measles and scarlet fever inhibit perspiration both 



of reducing temperature which inhibits the elimina- 
tive and excreton' functions of the skin defeats the 
most logical indication for therapy that we have in 
the acute infectious eruptive diseases. A gentle 
perspiration during the course of the eruptive stage 
of measlesand scarlet fever is desirable, and all ther- 
apy should be directed toward its encouragement. 
Whenever a case of measles or scarlet fever with high 
temperature and other toxic phe- 
nomena shows but a scant and 
incomplete eruption. I practice 
and advise the giving of a warm 
bath followed by a dry pack. 
The perspiration which ensues 
is generally successful in bringing 
out the eruption, while at the 
same time the temperature will 
sink materially and the curve be 
completed on a lower plane. 

This is onl)!- done if with hyper- 
pvrexia the eruption is incomplete. 
To reduce abnormally high tem- 
peratures (above 104°) in uncom- 
plicated or complicated measles or 
scarlet fever, I have used for some 
years the following method : The 
patient is placed in a bath with 
the water at a temperature of 
So'F. ; at the end of five or ten 
minutes, depending upon the case, 
the temperature of the water is 
raised to 90" by the addition of 
warm water. A bath at 80' for 
a fever patient with temperature 



of 105° is a cooling bath, and yet not cool enough 
to produce the evil effects upon the capillaries of the 
skin of which I spoke above. The subsequent raisivg 
of the temperature of the water ten degrees for ten 
minutes is equivalent to giving a warm bath after the 
cool one to the patient who has become accustomed to 
the water at 80', Whatever ill effect the cool bath 



July 2, 1904] 



MEDICAL RECORD. 



at 80" imay have had upon the cutaneous capillaries 
and nerves is more than counterbalanced, and yet 
the temperature of the bath is still at 90' — much 
lower than that of the skin. The patient, when 
taken from the bath, is wrapped lightly in a sheet 
and covered lightly by a thin blanket. The tem- 
perature will be found to have declined from one and 
one-half to three or more degrees, and the decline 
persists longer than from any other method that I 
have tried in these diseases. Moreover, the eruption 
is not diminished, the pulse is improved, sleep 
generally induced, and a gentle perspiration covers 
the whole body. Practically, one point of impor- 
tance must not be forgotten. When the warm water 
is added it must be poured into the bottom of the 
bath tub. The reason for this is that if the warm 
water is poured on the top, it floats over the cool 
water, unless imperfectly mingled mechanically by 
the nurse. The patient would thus have the lower 
part of his body bathed in cold water and the upper 
part in warm or hot water. For this purpose I have 
used in private houses a tin funnel with a piece of 
rubber hose long enough to reach to the bottom of 
the tub, and thus the warm water is delivered at the 
bottom of the bath. It then rises by its own light- 
ness, as compared with the cold water, and is dis- 
seminated throughout the bath. For hospi.tals, a 
tub with a false fenestrated bottom can be made, 
and a permanent tin tube passed along one of the 
sides to the bottom, to accomplish more easily the 
same purpose. The patient should not be rubbed 
after such a bath, both because the warm additional 
water accomplishes all or more than the rubbing in 
the Brand bath, and for the further reason that 
friction is detrimental to the inflamed skin, 
producing a pseudo-desquamation long before the 
subjacent skin is ready to cast off its inflamed 
covering. Such desquamated areas of skin are 
practically superficial ulcers. 

Lesser degrees ®f hyperpyrexia are treated by 
sponging with water at 70*, to which one -third 
ordinary alcohol has been added. The alcohol in 
these cases acts the part of the added warm water 
in the bath, and counteracts the ill effects of the 
cold sponging upon the capillaries and nerves of the 
skin. It is unnecessary to again repeat the in- 
junction against the use of friction upon the skin. 
On the contrary, the sponging should be liberally 
done with a large soft sponge, only the excess of 
water absorbed by patting the skin with a soft towel 
and the patient lightly covered as after a bath. 
Of these two methods the most efficacious in very 
high temperatures of scarlet fever and measles has 
been the tub bath as above described. 

With a knowledge of what is the normal and 
expected course of the temperature in uncomplicated 
cases of these diseases, we should be able from 
carefully kept charts to receive mxxch aid in the 
differential diagnosis of these affections when they 
resemble each other, in the early recognition of com- 
plications and in the prognosis of individual cases. 
We should be able to estimate at their true value 
specific sera that may be recommended for the 
treatment of measles and of scarlet fever by their 
effect upon the normal temperature curve. The 
efficacy of the methods I have described for the 
treatment of hyperpyrexia in these conditions will 
be my excuse for a conscious offense against unity, 
in thus discussing or combining in one paper two 
closely allied, but yet separate and distinct topics. 

The charts from the cases in the Riverside 
Hospital were furnished me by Dr. Watson, acting 
resident physician, and Dr. Horwitz, interne, at the 
Riverside Hospital, to both of whom I hereby ex- 
press my sincere thanks. 

921 Madison Avenue 



GRAVE AN/EMIA DUE TO HOOK-WORM IN- 
FECTION.* 

By LOUIS M. WARFIELD, A.B., M.D.. 

SAVA.VN.\H. GA. 
FORMERLY HOUSE MEDICAL OFFICER OF THE JOHN'S HOPKINS HOSPITAL. 

The recognition of the true etiology of a group of 
anaemias prevalent in our Southern States is of 
comparatively recent date, and the role played by 
the intestinal worm. V ucinaria americana (Stiles) 
is as yet little appreciated. The succession of 
events from 1901, when Stiles made the suggestion 
that we probably had in our midst a worm similar 
to, if not identical with, that found in Egypt, Eu- 
rope, and the Tropics, which caused the so-called 
"brick-makers' anaemia," "miners' cachexia," etc., 
to the present status of Uncinariasis, has been both 
rapid and startling. W'ho would have supposed 
that within two short years all our ideas of one 
group of anaemias, in the South especially, would 
be so upset? From time immemorial malaria and 
the miasm of swamps have served as diagnostic 
rubbish heaps, where practically all cases of anaemias 
were indiscriminately thrown. Now, however,- 
thanks to the labors of Stiles, Ashford, Harris, and 
others, we are waking up to the fact that we have 
a disease easy to diagnose and easy to cure that is 
responsible to a great extent for the lifelessness and 
unproductiveness of the country commimities. 
Strange it is that a disease so easily recognized 
should so long have waited to be accurately diag- 
nosed. It represents a triumph for science and 
microscopical methods in the hands of earnest 
seekers after truth. 

The cases reported are few. Case 5 in particular is 
the only one of its kind that I have seen or heard 
of. The interest lies in the fact that it suggests 
possibilities of mistakes in diagnosis, and for this 
reason more than any other I present the case. First, 
let me relate briefly the histories of four other 
cases: 

Case I. — Wm. C, age twenty, white, comes from 
Higgston, Ga., admitted to the Savannah Hos- 
pital, August 18. 1903. complaining of sores on 
penis. He says all his family are tall, well-built 
people. The patient up to ten years of age was well, 
except for chicken-pox. At age of ten he had rheuma- 
tism, which confined him to bed for nearly three 
years and left him a cripple. He has had ground- 
itch five times, the last attack three years ago. 
He lives among the pinej^ woods on sandy soil, and 
says that many sallow people are in the town. 
Three months ago he contracted a venereal sore, 
which was diagnosed as chancroid. He has lost 
in the past year some weight and much strength. 
For our purpose his present illness began about 
ten months before admission. He began "to go 
down hill." felt drowsy all the time, and had a dis- 
disinclination to move around. Does not think 
his disposition has changed. No loss of appetite, 
no diarrhoea at any time, and he never noticed 
that his stools at any time contained blood. Has 
suffered with shortness of breath and palpitation of 
the heart. Physical examination shows the pa- 
tient to be undersized, underdeveloped, and dull 
intellectually, about 5 feet 3 inches in height. Small 
dressing on bridge of nose where abscess was 
opened. W'alks on crutches. Complexion sallow, 
mucous membranes pale; very few vessels can be 
seen in conjunctivae. Sclerotics of normal white- 
ness, pupils slightly dilated, equal, react normally. 
Soft systolic murmur at second left interspace. 
Heart not enlarged. Pulse regular in force"~and 
rhythm, good volume, rather low tension, 20 to \. 
Abdomen flat, no tenderness. Spleen felt extend- 

*Read before the Georgia Medical Society. 



lO 



MEDICAL RECORD. 



[July 2, 1904 



ing 6 cm. below costal margin. Liver not en- 
larged. Healing sores on penis. Testicles small, 
no nodules. Legs show typical picture of arthritis 
deformans. The patient was seen by me on Sep- 
tember 16. A specimen of stool showed numerous 
ova of uncinaria in all stages of segmentation. 
The stool had a peculiar granular appearance, 
dark brownish-red in color, with a curious odor 
which was not disagreeably fecal, combined with 
an odor somewhat resembling stale blood. A piece 
put on a sheet of white paper and allowed to stand 
for an hour left a reddish-brown stain, which is said 
to be of diagnostic value. 

September 18. — Thymol was given in divided 
doses, followed by castor oil. All stools were lost. 
Since admission the patient has had an irregular 
temperature, reaching almost every afternoon to 
99° or loo" F., returning in the morning hours 
nearly to, or quite to, normal. 

September 19. — Temperature subnormal, and 
up to the time of discharge on September 26, it 
was never 99° F. The patient was given two 
other courses of thymol, but through some mis- 
understanding all the stools were lost. 

September 25. — Discharged at his own request. 
He is much improved, but a few eggs are still to be 
found in the stools. 

C.\SB II. — Wm. S., age eighteen years, Screven, 
Co., Ga., complains of shortness of breath and 
feeling badly. This patient was under the care 
of Dr. Carter, at whose suggestion I examined the 
stools. The patient says his family are well. All 
are full-sized. His father used to be sickly, but 
now seems quite well. He himself has always 
been sickly. Used to feel tired and drowsy, and 
was subject to attacks of diarrhoea. He has had 
repeated attacks of grounditch, the last attack 
two years ago. For some time he has been a mes- 
senger boy. His health at present is much better 
than it ever has been. The patient was seen by 
me on September 14. He had been under Dr. 
Carter's care for several months, and had improved 
considerably under treatment with iron and tonics. 
He had had a dilated heart and all the symptoms 
of grave anaemia. He had constantly a low fever 
from 99° to 100" F. Status prassens: A markedly 
sallow, underdeveloped boy, cheeks puffy and skin 
tough, parchment-like, yellowish in color. Mucous 
membranes exceedingly pale, lips dry and full of 
fissures. Eyes bright, pupils not dilafed, react nor- 
mally, tongue clean. Chest small, but normal; 
lungs negative. Heart's apex in fourth inter- 
space inside nipple line. No increase in dulness, 
no thrill. A soft systolic murmur heard all over 
left chest, loudest at second left interspace. Arm 
and legs thin. Abdomen a trifle full. Spleen 
and liver readily felt; no oedema. Genitalia not 
developed. Stool formed, same characters as 
Case I. Very numerous ova found on micro- 
scopical examination. 

September 27: Thymol given, followed by castor 
oil. A small specimen of stool passed at 4 p.m. 
seen. All other stools lost. 

September 28: Blood count: reds, 4,152,000; 
whites, 10,500; haemoglobin, 43 per cent. Stained 
specimen showed numerous eosinophils; slight 
irregularity in the size of the red cells ; no nucleated 
red cells seen. The patient was discharged Sep- 
tember 29. 

November 10: On microscopical examination 
of a specimen of stool many eggs are still seen. 
The patient says he never felt better in his life. 
He is gaining weight and color. 

C.^^sE III. — Harry W., white, Camden Co., Ga. 
I am indebted to Dr. Corson for permission to re- 



port this case. The patient was bom in Syra- 
cuse, N. Y. He was taken by his parents when a 
few months old to Camden County, where his 
people have since lived. He entered the Savannah 
Hospital October 3, 1903, complaining of a gun- 
shot wound of the right arm. His parents are liv- 
ing and well. He has three brothers and one sister, 
all of whom look pale and sallow ; have had repeated 
attacks of grounditch, and chills and fever. He 
has always been well, except for attacks of chills 
and fever, occurring, as a rule, in the fall. He 
has had repeated attacks of diarrhoea, but has 
never noticed blood or mucus in the stools. His 
appetite is good. He goes barefoot, and has had 
several attacks of grounditch. He does not admit 
much shortness of breath or palpitation of the 
heart. He says that near where he lives are many 
people who eat pine straw, and are said to eat dirt. 
He is sallow, yellowish, anaemic, quite intelligent, 
eyes bright, sclerotics have a slightly yellowish 
tinge. The conjunctivas are almost white, tongue 
slightly coated. A hsemic murmur heard at the 
second left interspace, and a palpable spleen which 
has a hard fairly sharp edge, are the onl}' points of 
interest. The right arm is bandaged from wrist 
to shoulder, and is laid on a pillow. He has had a 
slight rise of temperature since admission. Oc- 
tober 9: A stool obtained was yellowish brown, 
homogeneous. On microscopical examination a 
number of ova of uncinaria were found. Blood 
count: reds, 2,596,000; whites, 9,000; hsemo- 
globin, 48 per cent. No malarial organisms found 
in fresh smears of blood; some pigment seen. All 
red cells are of equal size; eosinophiles not numer- 
ous, but appear slightly increased in numbers. 
October 10: The patient was given thymol, fol- 
lowed by castor oil. 

November 10: No eggs were found in the stools 
after careful search. The patient has more color 
and says he feels better than he has ever felt. 

C.'VSE IV. — Gussie M., age fourteen, white. Way- 
cross, Ga. Admitted November 12, complaining 
of fever. Family history negative. She has always 
been well, but has never been very strong. She 
has always been pale, suffers from shortness of 
breath; has never had diarrhoea; appetite good. 
Menstruation began at age of twelve, and has 
always been regular and painless. She has had 
several attacks of grounditch, the last attack 
two years ago. She has never had malaria. While 
in South Carolina recently she had dumb chills, 
followed by sweats. No vomiting, no nausea, 
some headache; loss of appetite. Hyaline asstivo- 
autumnal malarial parasites were found in fresh 
smears of blood. Temperature on admission was 
ioi°F. She was given quinine, and in a few 
days her temperature was normal, and has re- 
mained so ever since. She is a well-nourished 
pale, sallow, girl, fairly intelligent. The mucous 
membranes are pale, the sclerotics have a slight 
yellowish tinge; pupils normal. Soft systolic 
murmur at second left interspace. Large tumor 
in abdomen, which is an eight months' pregnancy. 
Spleen not felt. Stool examined November 16 
was brownish, fairly homogeneous. Numerous eggs 
were found on microscopical examination. Blood 
count: November 19, reds, 3,920,000; haemoglobin. 
55 per cent. Stained specimen showed one cres- 
cent; red cells slightly irregular in size; nucleated 
red cells seen; no noticeable increase in the eosino- 
philes. Patient not to be treated until after de- 
livery. 

C.\SE V. — This is the case to which I wish par- 
ticularly to call attention. It illustrates one phase 



July 2, 1904] 



MEDICAL RECORD. 



II 



of the infection with hook-worms which I have 
suspected occurred, but so far have seen but this 
one patient. Lina T., age twenty-one, white, 
single, was seen on November 10, when she com- 
plained of pain in the back, chilly sensations, and 
fever. She comes from Screven Co., Ga. Both 
parents are dead, causes unknown. She has two 
sisters and two brothers living in Savannah. All 
are well, except a younger sister, who is pale and 
sickly. She has always been sickly, and has never 
been able to do much work, as she tires very easily. 
She had scarlet fever two years ago; no sequelae. 
She had chicken-pox when a child. Up to two 
years ago she had grounditch every summer; the 
attacks were severe. Menstruation began at age 
of fourteen; her periods have always been scanty, 
irregular, and accompanied with some pain. She 
has had at times a slight leucorrhoea. Occasionally 
her feet and ankles have swollen, but she has had 
no urinary troubles. She has had some irregularity 
of the bowels, and attacks of diarrhoea. Appe- 
tite usually good. She works in the American 
Cigar Factory here. On November 10 she was 
seized with chilly sensations, pain in the back 
and loins, and fever. For several days previously 
she had been feeling unwell. The pains were so 
severe that she was forced to go to bed. She 
has had no trouble in passing urine, did not think 
it was abnormal in color, and she has had no sup- 
pression. Bowels regular, appetite lost. The pa- 
tient was seen at night by the light of a small 
lamp. She was lying on the right side, and seemed 
in pain. A fairly well-nourished girl, but markedly 
ansemic, skin pasty white; eyes puffy; mucous 
membranes pale; tongue slightly coated; lips 
fissured ; the under lip showed herpes, and several 
excoriations. Pulse 30 to } regular; low tension; 
fair volume. Temperature 101.4° F. There were 
a few rales in the lungs at the bases. A loud 
systolic murmur was heard all over the left chest 
in front; loudest at the second left interspace 
over the pulmonary area. No thrill was felt. 
The apex beat was inside the nipple line in the 
fourth interspace. Abdomen negative, except for 
pains in both loins on deep pressure. There was 
distinct oedema of both shins, knee-jerks normal. 
There was no specimen of urine but the signs and 
symptoms were so suggestive of a nephritis that 
she was treated as such, and she was told to have a 
specimen of urine ready at the visit next morning. 
November 1 1 : This morning there is no fever. 
The complexion is seen to be sallow, parchment- 
like. Her anasmia is seen to be profound. A 
specimen of stool was obtained and the suspicion of 
uncinariasis was confirmed by finding enormous 
numbers of eggs. The stool was exactly like that 
described in Case I. Urine examination showed 
a clear urine, slight fliocculent precipitate acid, 
sp. gr. 1012, no albumin, no sugar. Novem- 
ber 13, temperature 99.4° F., pulse 30 to {. The 
patient is up and says she feels about as usual. 

Blood count showed red cells 3 , 1 60,000 . haemoglobin 
27 percent. In a stained specimen one sees that the 
red cells stain faintly; they are irregular in shape and 
size and show some chromatophilic degeneration. 
There is a decided increase in both the eosinophiles 
and small mononuclear cells. Normoblasts are 
also present. The patient was sent to the Savan- 
nah Hospital, where she could be observed and 
treated better than at home. 

November 14: Temperature 99.6-100* F. Thy- 
mol was given in divided doses, followed later by 
castor oil. In the stools large numbers of male and 
female uncinariae were found. November 16: 
Temperature 98.6-99° F. Thymol was again given. 



followed by castor oil. A number of worms were 
found in the stools. November 18: Temperature 
has been normal since last note. Discharged im- 
proved. December 20: The patient has gained in 
flesh and strength. Eggs are still found in the 
stools. She will be given another course of treat- 
ment. 

These few cases serve to illustrate the point that 
I wish to bring out, viz., that in cases of anemia 
one should always examine the stools for intestinal 
parasites. If the case has come from the country, a 
child or young adult, and gives a history of previous 
grounditch and attacks of diarrhoea, one is sure to 
find eggs of the hookworm in the stools. The num- 
ber of eggs found is, as a rule, in proportion to the 
severity of the anaemia. 

From studies that I have been able to make 
around Savannah, I am led to the conclusion that 
(i) The anaemias of the country' districts are due in 
the great majority of cases not to malaria, but to 
uncinariasis; and (2) that in almost all cases of 
uncinariasis there have been previous attacks of 
grounditch. That the connection between these 
two diseases is a close one seems beyond doubt. 
The idea was advanced by Looss only two years 
ago, tut evidence is daily accumulating tending to 
show the intimate relationship between the two con- 
ditions. Bentley has found in the water sores of 
panighao, which evidently is similar to our ground- 
itch, embryos which he identified as those of Aiiky- 
lostoma duodenale. That is very significant, and 
I believe that when grounditch is carefully studied in 
the light of our present knowledge, we shall have 
ample confirmation of his work. 

Elsewhere I have expressed the belief that 
uncinariasis may at times give rise to a fever simu- 
lating typhoid or sestivoautumnal malaria. That 
there is a long-continued fever in the severe grades, 
three of the foregoing cases show. One shows that 
an acute exacerbation of a puzzling character may 
take place. In such cases it is of paramount im- 
portance to make an exact diagnosis, otherwise 
whatever treatment we use only temporarily 
betters the condition. From the histories and 
general appearances, cases of uncinariasis may re- 
semble those of pernicious an.-emia. The examina- 
tion of the stools alone settles the diagnosis. The 
blood conditions in the two diseases may be similar 
except for the eosinophilia, which always occurs in 
grave cases of uncinariasis. One condition is 
easily curable, the other is rarely ever cured. 

For a proper interpretation of microscopic blood 
changes, however, special training is necessary', 
whereas any one who can see through a magnifying 
glass can look for and recognize uncinaria eggs under 
the low power of a microscope. A small piece 
of stool the size of a pin-head is put on a slide and 
mixed well with a drop of plain water. On this a 
coverslip is dropped and the slide then examined 
with Leitz ocular 3, objective 3. In cases of 
severe infection one usually focuses immediately 
on an egg, and one sees at times ten or a dozen 
eggs in one field of the microscope. The whole 
procedure takes not longer than a minute, hence no 
one should ever be too busy to devote that time 
to making an accurate diagnosis on his patient. 
This is all the more important when we know that the 
treatment is so simple and generally so successful. 
Without the diagnosis no treatment is of any 
avail that does not attack the cause of the trouble. 
With our present knowledge we may be morally 
certain of hook-worm disease from the history and 
general appearance of the patient, and if there is 
no means of verif\-ing microscopically our suspicion, 
we can give specific treatment and tell the patient 



12 



MEDICAL RECORD. 



[July 2, 1904 



to look for small, thread-like worms in his stool, 
and have him bring a specimen for inspection. 
The truth is that we must all laj' aside our precon- 
ceived notions that all anaemias and all sallow com- 
plexions can be caused only by malaria, if we have 
any such ideas, and lay it all to hook-worm in- 
fection until we prove any individual case to the 
contrarj' after careful stool examination. It is 
far better that the pendulum should swing com- 
pletely over, and that we should believe all ansemias 
to be due to hook-worm infection and none to 
malaria, than that we should jog along as we have 
done and yearly sacrifice thousands of lives on the 
altar of inherent prejudice to new ideas. Let the 
profession at present look with suspicion on ground- 
itch, preventing it whenever possible, and when 
present curing it without delay. Let us take the 
attitude of the Saxons that a man is guilty until he 
is proved innocent and apply it to grounditch. We 
may be mistaken in laying so much stress on an 
antecedent grounditch as the cause of hook-worm 
disease, but the facts at present at our command 
warrant us, in the writer's opmion, in believing 
such an hypothesis. 

It is also of interest to note that in high grades 
of anamia, from whatever cause — neoplasm, hemor- 
rhage, pernicious anaemia, uncinariasis, malaria, 
etc. — there may be oedema and even anasarca, and 
there is in most cases some fever. The fatal termi- 
nation is at times preceded by delirium, high tem- 
perature, and even mono- or hemiplegia. 

The treatment of the cases is simple and success- 
ful, although in severe cases it is necessan.' to con- 
tinue specific treatment at intervals until the stools 
are free from eggs. One gives an adult castor oil 
or Epsom salts in the evening. There must be no 
food whatever given from then until noon of the 
following day. At 8 a.m. 30 grs., 2 grams, of finely 
powdered thymol are given either in capsule or 
with a little water. At 10 a.m. another dose of 
30 grs., followed at noon by a large dose of castor 
oil or salts ( 3 I-II). In order to facilitate the 
action of the thymol some give whiskey or brandy 
with it, but as the combination has proved on several 
occasions to possess distinct depressing and toxic 
actions, it is safer to administer the drug in capsules 
or with water alone. 

Finally, let me urge my fellow-practitioners to be 
on the watch for cases of anaemia, especially in 
children and young adults who come from the 
country. I know that some of you do not agree 
with me when I lay so little stress on malaria as a 
cause of anaemia. I ask you to take careful his- 
tories, make, when possible, blood and stool ex- 
aminations, and I feel sure that before you have 
made many such examinations you will agree 
with me that it is the hook-worm that causes, and 
has caused, such suffering to our country people. 
It is with us in the South a serious economic problem, 
and we caimot start too early to band together to 
fight it intelligently. 



Percussion of the Pulmonary Apices. — Jundell discusses 
the possibilities of making errors in doing this, and es- 
pecially the fact that percussion is very apt to be carried too 
far to one side or the other. He suggests that in percussing 
the supraclavicular fossa, a point be selected which 
lies just above the clavicle and at the outer border of the 
clavicular portion of the stemomastoid muscle. The 
finger should be so placed that its volar aspect is directed 
backward and only very slightly downward and toward 
the median line. When percussing the fossa supraspinata 
the same precaution should be taken to place the finger 
so that the percussion stroke is at right angles to the 
surface of the lung. — Zentralblatt fur innere Medizin. 



ACUTE TETAXUS CURED BY INTRANEURAL 
INJECTIONS OF ANTITOXIN. 

By JOHN ROGERS. Jr.. M.D., 

NEW YORK. 

The following case corroborates very strongly the 
experiments with tetanus in animals which demon- 
strate' the curability of the disease by injections of 
antitoxin into the motor nerves of the part primarily 
infected. 

J. M., a boy of eleven years, sustained a 
punctured wound of the sole of the left foot from 
a rusty nail. This occurred on the afternoon of 
Monday, April 25, 1904. No attention was paid to 
the injury, and beyond some soreness no symptoms 
resulted until seven daj-s later, or Monday, Maj* 2. 
On arising at 6 a.m. this day he complained of some 
stiffness about the jaws and neck and was unable 
to eat breakfast. 

He was brought to Gouverneur Hospital at 10 a.m., 
where examination revealed marked trismus with 
risus sardonicus and stiffness and rigidity of the 
muscles of the back of the neck. There was a small 
punctured wound in the anterior part of the sole of 
the right foot just to the outer side of the ball of the 
great toe. Pulse no. Temperature 99°. He was 
immediately put to bed and given 20 c.c. of anti- 
toxin subcutaneously and this dose was repeated in 
the afternoon. At 6 p.m. the rigidity of the neck 
had extended to all the muscles of the back and the 
jaws were tightly closed. 

May 3. During the night the condition had 
become worse and the apisthotonus was so marked 
that he was placed on his back with pillows under 
the lumbar and shoulder regions to relieve somewhat 
the strain from the backward extension of the head 
and legs. At 11 a.m. Dr. Elliot, under whose care 
the case had been, kindly consented to allow me to 
try the efficacy of the intraneural injections of anti- 
toxin which had proved so successful in the previ- 
ous case, and therefore under chloroform anaesthesia, 
with every antiseptic precaution, the anterior 
crurae nerve was exposed just below Poupart's liga- 
ment and about 3 ss of antitoxin injected into its 
substance. The same procedure was adopted with 
the great sciatic nerve opposite the gluteal fold pos- 
teriorly. A rather fine needle was employed, and 
while the nerve was held on the index-finger the 
needle was several times withdrawn and reinserted 
into the substance of the trunk to insure some 
wounding of the nerve fibers, as experimentally this 
seems an essential matter to secure entrance for the 
antitoxin. The patient was then turned over and 
the needle introduced into the spinal canal between 
the lamintE of the second and third lumbar vertebrae. 
The needle was manipulated back and forth in the 
spinal canal until its motion produced a twitching 
of the left leg (the right leg contained the source of 
infection). This was intended to make at least an 
abrasion of some of the nerves in the cauda equina, 
and the twitching was considered evidence of the 
success of the manoeuvre. The escaping cerebro- 
spinal fluid contained no blood. Antito.xin 3 iss, 
was then injected into the spinal canal subdurally. 
The wound in the foot was next laid widely open, a 
small foreign body, apparently a piece of leather, 
and a little pus and necrotic tissue scraped out and 
the raw area swabbed with tincture of iodine and 
packed with iodoform gauze. A culture made from 
the wound was reported later by Dr. Letchworth 
Smith, bacteriologist at the Cornell Medical College, 
to contain numerous tetanus bacilli. At the con- 
clusion of the operation there was found to be a 
noticeable relaxation of the rigidity, which persisted 
until recovery- from the effects of the anaesthetic 
(chloroform). This relaxation occurred with each 



July 2, 1904] 



MEDICAL RECORD. 



13 



subsequent anaesthetization and seemed to me of 
appreciable benefit. During the night following (of 
May 3) the condition again grew worse and there 
were four separate convulsive seizures, each lasting 
about ten minutes. 

May 4. The condition seemed hopeless; the 
opisthotonus was, if anything, worse than in the 
previous morning, but there had been no recurrence 
of the convulsions noted in the early part of the 
night. Not even water could be given by mouth. 
The temperature was 103° and the pulse 120. As 
the outlook could not be made worse, I decided to 
make one more trial of the antitoxin near the 
vital centers, and therefore, under chloroform anaes- 
thesia, inserted a rather fine needle with a long point 
into the spinal canal between the laminae of the 
second and third dorsal vertebras. After the needle 
was felt to pass between the laminae it was pushed on 
until it impinged against the bodies of the vertebrae 
in front. In other words, an attempt was made to 
puncture the dorsal cord, and though no blood tinge 
occurred in the escaping cerebrospinal fluid, I can- 
not see how the cord could have escaped some 
wounding by the long, fine point. At any rate, 
3 iss of antitoxin was injected while the tip of the 
needle was felt to toitch the posterior surface of the 
vertebral body. The only reaction noted was 
marked contraction of the pupils and a slight slowing 
of the pulse. Opportunity was taken of the anaes- 
thesia to redress and swab with tincture of iodine the 
wound in the foot. 

During the rest of the day and through the night a 
very remarkable improvement took place. 

May 5. In the morning it was found that no 
convulsions had occurred. The rigidity of the back 
and legs had largely disappeared and the mouth 
could be opened about half an inch. The improve- 
ment was so great that it forced me carefully to 
review the previous conditions, and then for the first 
time I made the humiliating discovery that in in- 
jecting the motor nerves of the leg I had entirely 
overlooked the obturator. The source of infection 
had probably been entirely eliminated at the first 
operation and the charge of poison on its way to the 
cord in the two chief nerves, the sciatic and anterior 
cruree, blocked, but the charge in the obturator had 
been allowed to flow upward and almost produce 
death. It had been stopped from reaching the 
vital centers only by the antitoxin injected ahead of 
it into the upper end of the cord. Whatever the 
explanation may be, the value of injecting motor 
nervous tissue and of previously producing a wound 
of this nervous tissue for the entrance of the anti- 
toxin seems to me abundantly proved by the injec- 
tion here into the dorsal cord. The condition of the 
patient was changed within a few hours from one of 
impending death to one of comparative well-being. 
And there is the less possibility of exception from 
this view because of its close analogy with the ex- 
perimental results previously referred to in the 
work of Meyer and Ransom. 

May 6. The condition of the patient was found 
on this day to have deteriorated somewhat from that 
noted during the previous twenty-four hours. It 
was so excellent on May 5 that no antitoxin had 
been given, but on May 6 the trismus had returned 
with some stiffness of the neck and back. Liquids 
which could be taken freely by mouth yesterday 
could not now be managed so well and had again 
to be supplemented by rectal alimentation. A 
lumbar puncture was therefore performed (under 
chloroform) and in manipulating the needle to 
wound the nerves there was produced a considerable 
flow of blood, perhaps half a drachm mixed with cere- 



brospinal fluid. But without waiting for it to cease 
Z iss of antitoxin was injected subdurallj'. The 
only result noted was contraction of the pupils and 
slight slowing of the pulse. During the afternoon 
and evening the patient seemed more comfortable 
and mouth feeding was resumed. 

May 7. The patient seemed perceptibly im- 
proved and could separate the teeth about half an 
inch. The neck and back were still quite rigid, but 
the extremities were entirelj^ relaxed. As no harm 
could result, and to forestall any possibilitv of re- 
lapse, another dose of 3 iss of antitoxin was ad- 
ministered by lumbar puncture. No more was 
given subsequently. 

May 8. Slow, but evident gain. In the past 
twenty-four hours he has been able to roll about in 
bed and professed to feel perfectly well if only he 
could "cheer." 

May 9. The improvement continues, though the 
trismus has not entirely disappeared, and did not until 
May 13. During the afternoon an extensive 
erj-thema began to appear on the abdomen and legs. 
On the following day this had spread to involve the 
whole trunk and had almost the appearance of 
purj^ura hreinorrhagica. But the pulse and temper- 
ature continued low, and on May 13 the rash had 
entirely disappeared as well as all the symptoms of 
tetanus. The wound over the anterior crural nerve 
had failed to unite and became infected. The wound 
in the sole of the foot was of course granulating and 
open. The wound over the sciatic had healed. He 
was eating regular house diet, and on May 18 he 
was out of bed and pronounced cured. 

To my mind the progress of this case has demon- 
strated without a shadow of dovibt the efficacy in 
tetanus of injections of antitoxin into the substance 
of the motor ner\'es of the part of the body primarily 
infected and into the spinal cord. From the wonder- 
fvil and rapid change for the better noted after in- 
jecting the antitoxin into the dorsal cord on May 4 
it might be argued that the motor nerves could be 
neglected, but in view of the experiments^ by Meyer 
and Ransom this would seem unsafe. The ex- 
posure of the nerves in the axilla or high up in the 
thigh is simple, and adds nothing to the gravity of the 
situation, and in the two cases I have reported really 
seemed very advantageous. My inexcusable neglect 
to inoculate the obturator nerve in this second 
case I am convinced led to the increase of symptoms 
on May 4. That they were checked by injecting the 
dorsal cord only goes to show the necessity of 
producing a wound of nervous tissue to secure en- 
trance for the antitoxin. This, by the way, is 
evidently the crux of the whole problem and seems a 
beautiful confirmation of a physiological fact, or 
perhaps theorj^ which is as remarkable as it is unique, 
namely, the complete isolation of at least some 
nerve cells from the circulating blood. • The tetanus 
toxin and the antitoxin can only reach these nerve 
cells through nervous tissue, and normally this 
course begins with the terminal filaments of the 
axis cvlinders. 



102 E-\sT Thirtieth Street. 



Erysipelas and Nephritis. — Nyrop gives the histories of 
two cases in which intercurrent erysipelas appeared to 
cure or improve an already existing nephritis. The first, 
already described by Langeballe, is that of a young woman 
suffering from a severe acute nephritis which cleared up 
entirely in the course of a moderately severe general 
ervsipelas. In the other case the albumin and casts did 
not entirely disappear but marked and permanent im- 
provement followed. — Zentralblatt fiir innere Medizin, 
No. 15, 1904. 



14' 



MEDICAL RECORD. 



[July 2, 1904 



THE NON-SIGXIFICANCE OF CLIXICAL 
SYMPTOMS IX DETERMINIXG THE PATH- 
OLOGICAL COXDITIOXS OF APPEXDI- 
CITIS.* 

By A. P. STONER, M.D., 

DES MOINES, IOWA. 

That the millenium in which the clinical diagnosis 
of the pathological conditions of the inflamed ap- 
pendix is not attained, is evidenced by the ex- 
perience of some of our most noted clinicians and 
operators. As one's experience grows with the 
diseased appendix, the less inclined we are to 
make positive assertions as to the conditions that 
will be met on the operating table. After having 
operated upon over two thousand cases, Murphy 
is quoted by Knott ("Transactions Iowa Medical 
Society," Vol. XX) as saying that "he did not 
pretend to know anything more of the pathology 
of a given case than that the patient had an in- 
flamed appendix which should be immediately 
removed." Xow and then we meet a case in which 
it is indeed impossible to say whether or not the 
patient has even "an inflamed appendix." In the 
early stages of appendicitis the pains are diver- 
sified over the whole abdomen, or may be confined 
to the gastric region. These phenomena are ex- 
plained by the fact that the superior mesenteric 
plexus which supplies the appendix also sends 
filaments to the intestines. In some instances 
in which a low grade of inflammation of the organ 
exists, the pains never become localized around 
the appendix, but during each attack or exacerba- 
tion of the disease, pain may constantly be ob- 
served in the gastric region. 

C.\SE I is an illustration of this type. Michael 
S., professional gambler, age forty-six; no specific 
history. Formerly drank to excess. His infatua- 
tion for cards was such that at times he would go 
without his meals for from twelve to twenty-four 
hours, after which he would grossly overindulge 
in food and drink. The trouble for which he sought 
relief began about six years ago in periodic spells 
of violent pains and vomiting. 

The attacks would readily pass away under 
proper treatment and leave no apparent trace 
of the disorder. He was under my observation 
about one and one-half years before the operation. 
Usually appearing after a debauch in diet, the at- 
tacks would invariably continue until relieved by 
opiates. When the stomach was emptied, purging 
would ensue. I often found him on the closet 
stool with a vessel between his feet, purging and 
vomiting at the same time, ejecting by these efforts 
only a little mucus or liquids. The accompanying 
pains could be compared only with the tortures 
of childbirth. Indeed I have seldom witnessed such 
agony from any cause. Although at this time he 
was not an habitu6, it required from one-half to 
three-fourths grain morphine to alleviate his suf- 
fering. The attacks came on at varying intervals 
of from three weeks to three months, and would 
last under proper treatment from two to six days. 
Rectal feeding usually had to be resorted to. After 
the attack he would be apparently well again and 
could eat all sorts of food. No pains or incon- 
veniences were experienced between attacks. The 
matter vomited was analyzed on several occasions 
and usually showed deficiency in hydrochloric acid, 
and the presence of lactic acid. At no time, even 
during the attack, was there any pyrexia. Pressure 
over McBumey's point could arouse no suspicion 
of a diseased appendix. The immediate region 
of the gall-bladder was apparently normal. Taxm- 
♦Specimens presented and cases discussed before the 
Des Moines Pathological Society, March 29, 190.5. 



dice was never present. Even during the attack the 
■ebdomen was always flat, yet no information cotold 
be obtained from palpation, etc. The attacks 
became so frequent and were of such severity 
that the patient became reduced to a mere skeleton 
before finally submitting to operation. He had 
now become a confirmed morphine fiend, using 
from .5 gr. to 1.5 grs. daily. He entered Mercy 
Hospital August 15, 1903, and was placed upon 
nutrient enemas. Following this he was cautiously 
fed by the stomach. It was not, however, until 
September 19 that his condition was such as to 
permit of abdominal section. Under ether anaes- 
thesia I opened the abdomen, beginning at the 
costal arch and extending downward three or four 
inches along the outer margin of the rectus muscle. 
I rather expected to encounter a diseased gall- 
bladder. This region, however, was apparently 
normal, as was also the stomach and pancreas. 
Strangely, the stomach presented no evidences of 
the abuse to which it had so long been subjected. 
The incision was extended downward to the ap- 
pendix, w-hich was found to be slightly enlarged 
and injected, and thoroughly adherent to the pos- 
terior border of the csecum. After the removal of 
the appendix, the wound was closed by two rows of 
continuous catgut, and interrupted skin sutures of 
silk-worm gut. The belly being scaphoid, some 
difficulty was experienced in bringing the walls 
of the abdomen together. During convalescence 
the patient proved to be extremely incorrigible, 
and the day following the operation was found sit- 
ting up in the bed. Subsequently he was chastised 
a number of times for the same offense. The 
stitches were removed on the seventh day, and the 
second night following the nurse found him out of 
bed sitting upon the commode in an effort to 
evacuate the bowels. My attention next day was 
directed to blood upon the dressings, and upon re- 
moving them, the ghastly spectacle of the abdominal 
contents met my gaze. The wound — a seven-inch 
incision — had been torn open from one end to the 
other. He was again prepared for operation, and 
taken to the operating room. It required con- 
siderable dexterity and patience to coapt and hold 
the edges of the wound together. The tissues had 
become softened and the sutures easily cut through. 
However, by the aid of through-and-through 
sutures of silk-worm gut, which were tied as the 
continuous sutures of catgut drew together the 
fascia and peritoneum ; the wound was thus finally 
coapted. The wound healed a second time by 
primary union. The stitches were allowed to re- 
main two weeks, and he was kept in bed an ad- 
ditional fortnight. It is now four months since 
the operation and the patient has gained 40 pounds 
and feels perfectly well. He still uses morphine, 
however. Although a number of surgeons ex- 
amined this patient with me, at no time did any of 
us seriously suspect that the appendix was creating 
the disturbance. 

C.\SE II. — The following case, upon which I 
operated a few weeks after the one just related, 
illustrates, on the other hand, the paucity of symp- 
toms sometimes observed in the most virulent 
types of the disease. Mr. S. B. L., age twenty- 
seven, was sent me by Dr. Swartslander of Huxley, 
Iowa. On Friday, October 31, he experienced 
pains in the abdomen, and drove to town to see 
his doctor. The doctor found him suffering from 
appendicitis, and advised him to return home 
and go to bed. On the following Sundaj' some 
tympanites developed, and the doctor was called. 
A saline purge was administered and the symptoms 
rapidly cleared away. Tuesday he was taken five 



I Illy 2. 1904] 



MEDICAL RECORD. 



15 



miles to the railway station in a carriage and brought 
to Mercy Hospital in this city, a distance of forty 
miles by rail. Examination revealed an induration 
over McBurney's point, slightly tender upon pres- 
sure. Otherwise his condition was apparently 
normal. Indeed, the patient stated that at no 
time would he have gone to bed had not his physi- 
cian and friends urged him to do so. However, he 
was anxious to have his appendix removed, and 
on the following Friday, November 6, exactly 
seven days from the beginning of his first and only 
attack, the operation was undertaken. Upon open- 
ing the abdomen, the region of the appendix pre- 
sented an apparently inextricable mass of adhesions. 
A large mass of partly disorganized omentum, the 
thickness of one's hand, was finally released, and 
after being tied off was completely removed. In 
searching further for the appendix, much more semi- 
gangrenous tissue was encountered and cleared 
away. Presently I came upon a pocket containing 
a mass, the size of a filbert, of semi-solid fecal matter. 
It seemed to have been extruded directly from the 
cacum, which organ was very much thickened and 
scarcely distinguishable from the mass of adhesions 
in which it was embedded. After having removed 
the fecal mass, and while still laboring under the 
impression that the cscum had been opened, I at- 
tempted to close up the vent, but the sutures cut 
through the softened tissues, and the stitches were 
of no avail. What was thought to be the base of 
the appendix now became visible, but it was not 
possible to extricate the appendix, so thoroughly 
was it embedded in the exudate. The opening 
being guarded by gauze, a longitudinal incision 
was made along the visible portion of the appendix. 
The incision included the peritoneal and muscular 
coats. The mucous lining was then grasped with 
forceps, and while traction was being made, the 
incision was prolonged until the other end was 
reached; which was found to be the base and to 
occupy the posterior border of the caecum. The 
supposed rupture of the caecum proved to be a 
perforation in the distal end of the appendix. The 
core of the appendix having been freed, it was 
ligated and the stump cauterized and covered with 
peritoneum. The wound was closed without drain- 
age. Nothing whatever marred the recovery until 
the seventeenth day after the operation, when 
thrombosis of the right femoral and saphenous 
veins developed. The temperature rose to 101° F., 
the pulse became accelerated, and much pain was 
experienced. This annoyance continued until No- 
vember 27, when the patient was again permitted 
to be out of bed. He left the hospital November 
31. To my mind it is almost a mystery how the 
insignificantly inflamed appendix in Case I could 
have been responsible for the profound symptoms 
manifested. It is none the less mysterious how- 
one could be up and about doing farm-w-ork with 
such a condition as was revealed in Case II. The 
deduction to be drawn from Case I is that a slightly 
diseased appendix may be responsible for a variety 
of symptoms that may be attributable to other 
organs. Case II furnishes additional proof that 
no case, however apparently mild, should be en- 
trusted to nature or drugs. 



Large Doses of Carbolic Acid in the Treatment of Plague. 

— Dr. J. C. Thomson gives particulars of 141 cases of 
plague treated -svith large doses of carbolic acid. One hun- 
dred and forty-four grains were given daily, divided into 
two-hourly doses of 12 grains each. The mortality among 
those so treated was only 36.4 per cent. — Journal of 
Tropical Medicine. 



HYGIENE IX GYNECOLOGY.* 

By C. a. von RAMDOHR, M.D., 

-S'EW YORK. 
PROFESSOR EMERITUS NEW YORK P0ST-GR.1DUATE MEDICAL SCHOOL; 
FELLOW OP THE .NEW YORK OBSTETRICAL SOCIETY; NEW YORK ACADEMY 
OF MEDICINE. ETC. 

In all branches of medicine hygiene is considered 
the most important factor in combating the source 
of disease, and so it is primarily in gynecology. 
Secondarily, hygienic treatment is the most valua- 
ble therapeutic agent in wrestling with women's 
troubles. 

Therefore, to oust the gynecologist from his 
present status as curative agent we must primarily 
prevent women's diseases by attention to women's 
hygiene. 

Starting from the very beginning the connubial 
bliss enters our consideration. Marriage between 
minors, between people, one of which is syphilitic, 
between near kin, between people who are by nature 
of their poverty unable to rear their young, ought 
to be prevented, if possible. For part of their off- 
spring would naturally only appear as natural 
weaklings, always complaining of very natural 
woes, while the other would be forced by circum- 
stances to enter the race of life before they are phy- 
sically able, and thereby show themselves as phy- 
sical wrecks in our general clinics. 

The influence which crowded quarters with their 
inherent absence of cleanliness and morals have 
upon the female child are well recognized. The 
consequence of bad morale is well known. The 
habits of the young girl deteriorate, and moral 
turpitude may be traced directly to the surround- 
ings. Not only does the poor young female child 
suffer from want of care of the mind in her morally 
corrupt atmosphere, but her body is not properly 
cleansed; her clothes are insufficient; her food 
is not well up to the standard in calorics, and last, 
but not least, by the attitude of her poor parents 
she is prevented from attending school "whenever 
that may be," to cure an insufficient degree of ig- 
norance which will be propagated on the next 
generation. Their interest will lie in making the 
little girl a self-supporting wage-earner at as early 
a date as the lax law will permit. Bent over the 
shuttle, or bending over other work like sewing, 
sewing in a sweat-shop, or working in crowded fac- 
tories for abnormal hours, the little girl lays the 
foundation of future sickness. 

Still wealthier parents' girls are hardly any better 
off. The bottle cannot equal a mother's nourish- 
ment and care. Children's balls are not conducive 
to a better standard of womanhood. A fashionable 
school will not help to raise the morale or the phy- 
sique of a fashionable girl. 

Thus, in trying to avoid, or make other people 
avoid any of the previous delicto of hygiene 
we stand as gynecologists on the point where we 
ought to stand regarding the prevention of women's 
troubles by hygiene. 

Now, supposing that we get in contact with a 
patient suffering from some female trouble, let us 
remember the great axiom "Mens sana in corpore 
5aMci," and as a corollary: Nulltis uterus (^-\- adnexa) 
nisi sanus in corpore sano. Ergo Mens sana = 
Uterus sanus, i.e. a healthy body contains a 
healthy mind, and a healthy uterus (and adnexa). 

To the greatest extent our patients suffer from 
subjective symptoms — they complain of pain, 
and consequently their nervous system is affected. 
They must be treated in a surgical way if necessary, 
or by medical therapeutics, either by medicinal 
agents or by hygiene. 

♦Paper read at a meeting of the New York Obstetrical 
Society. 



i6 



MEDICAL RECORD. 



[July 2, 1904 



The first thing for us gj'necologists is to make a 
thorough and complete diagnosis. By exclusion, 
by objective examination, the cause of our pa- 
tients' trouble ought to be established, should such 
require surgical interference — for example, for 
tumors benign or malignant, pus collections, re- 
pair of lacerations, removal of degenerated mu- 
cous membrane, dilatation, dislocation — in fact, 
anything that would objectivelj' show a degenerated 
organ or interference with normal functions — well 
and good, let our proper surgical demanded work 
precede all other curative measures, always keeping 
in mind that this is done for a subjective painful 
symptom for which the patient is likely to consult 
us, and which we are trying to relieve. 

But these are not surgical procedures but make- 
shifts, if we remove organs not unhealthy, diagnosed 
because patients complain of pain in their respec- 
tive regions. 

We are past the period of clitoridectomy, past 
the period of oophorectomy and salpingectomy, 
past even the period of nephropexy, and last, but 
not least, indifferent curettage for subjective 
symptoms only. I say, we are, I mean the Eastern 
gynecologists, and the people in the West, South, 
or North who are abreast of the profession. 

Only lately I came across a female wreck, who 
had been carved by a St. Louis artist, and after 
four operations had both her kidneys anchored, 
appendix, uterus, and adnexa removed, and who 
begged pitifully for the relief of pain for which 
she originally consulted her physician. All opera- 
tions make a strong impression on the woman's 
mind, relieve her of her complaint, but onh' for a 
certain time. 

Massage of the uterus and adnexa so grandly 
introduced have failed, except in certain selected 
cases. The rest cure has only lately fallen asleep. 
Hypnotism and suggestion. Christian Science, and 
hydrotherapy, and Kneippism are looked on through 
different spectacles from formerly. Nowadays 
each up-to-date g\-necologist tries the newest fad, 
i.e. electricity in one or the other forms. But 
if the nerve specialists acknowledge that this thera- 
peutic agent will only act curativelj' in 25 per cent. 
of their cases while 75 per cent, are benefited only 
by the sensations, what is there in gynecology to 
permit the indiscriminate application with a view 
of curing the disease? We may relieve symptoms 
but not cure the cause. Let us now consider the 
local treatment of uterine affections. Deviations 
of the uterus which produce painful symptoms 
or may be the cause of sterility will, of course, 
be benefited by restoring the organ to its original 
position. 

As we know that almost a majority of copulating 
women's troubles are the result of the gonococcus, 
God bless our confrere Noeggerath for his inven- 
tion, and Lawson Tait for his original technique — 
the local effort of stamping out the cause will be 
of the highest importance. Hot or cold douches 
for inflammatory troubles plus glycerin tampons 
cannot be dispensed with. Whether paintings 
with one or the other agent for plain endometritis 
are of any but impressionable advantage, I have 
my serious doubts. 

Medicinal agents are good either as a placebo 
or as aperients or ferruginous compounds, as most 
of our patients are subject to anaemia and consti- 
pation. Ergot has prevented many a fibroid opera- 
tion, but of all others, practically, I have my doubts. 
Knowing that all aches and pains (and it is 
primarily the object of finding relief from those 
that the gynecologist is consulted) are the result of 
sensitiveness, and as sensations are relative and 
a subjective symptom which cannot be appre- 



ciated objectively by any other person, and know- 
ing that otherwise healthy women are least sensi- 
tive comparatively, therefore, a course of general 
treatment can only conduce to the health of the 
individual — that is, in our case to the female patient. 
This general treatment is called hygeine. Any 
and all women will be benefited, and some will be 
restored to health and happiness. 

Being consulted b}' a patient, and having heard 
her complaint, which practically will consist of pains 
in the back or abdomen, leucorrhoea.etc. after having 
carefully excluded heart, kidney, lung trouble, etc. ; 
after having carefully excluded a diseased or mis- 
placed genital organ which might need surgical 
or local treatment, it behooves us to inquire care- 
fully into the marital relations, the mode and 
frequency of coition, the means taken to prevent 
conception, and remedy whatever is possible in 
this direction. To go into details would be an 
insult to your intellect. 

The house surroundings and mode of living 
ought next to be studied: whether the patient 
is kept too warm, or too cold, whether the fresh air 
supply is sufficient (open windows, ventilators, 
heating apparatus, etc.); what an amount of care 
she takes in the household management, or what 
work she performs, what food she partakes of or 
craves for, the hours of meals, the recreations — 
reading, for example, the theater, balls, parties, 
or athletic exercises, etc., what stimulants she 
partakes of. or what narcotics (alcohol, coffee, 
tea, tobacco, morphine, chloral, bromine, etc.), 
and in what quantities. The care of the skin and 
teeth is next in order, and last, but not least, her 
mode of dressing: shoes, heels, corset, underwear. 
That her stools ought to be attended to is self-un- 
derstood; also the general care of the period of 
menstruation; ditto the support of a pendulous 
abdomen. 

Once more I only need mention these points to 
remind you of their importance. 

There is but one point more to which I would call 
your attention. Physical exercise is usually over- 
done, unless carefully prescribed and superintended. 
Six-ounce dumb bells are better than two-pound 
ones. A walk of half a mile is better than one 
of several miles if it tires the patient. 

It is with this graduated and superintended 
hygiene that the well-known watering-places in Eu- 
rope obtain their stupendous results. In the treat- 
ment of females: Absence from home influences 
and the husband; fresh air, baths, and spongings 
carefully administered ; carefully prescribed exer- 
cises, attention to diet and digestion, early hours — 
all these hygienic measures do more toward curing 
a patient of her symptoms than long continued 
local or symptomatic treatment indiscriminately 
employed. 

4S Irving Pl.^ce. 



Typhoid Fever and Its Treatment. — B. A Bobb present 
the following conclusions: (i) Typhoid fever is self-lim- 
iting disease which can often be modified and shortened 
in its course, and often aborted if treatment is instituted 
early in the course of the disease. (2) Where early elim- 
inative, antiseptic and hydro-therapeutic treatment is 
instituted there is not the dry tongue after the first few 
days. The tympanites is absent or nearly so, and there 
is not the exhaustive diarrhoea. (3) The temperature is 
easily controlled by sponge baths. (4) There are cases 
wherein complications develop that will call for a most 
careful study of the case in question. (5) It is the dvity 
of every physician who has cases of typhoid fever in charge 
to use e\ery prophj'lactic measure to prevent those who 
have the care of patients thus afflicted from contracting 
the disease. — The Medical Herald, March, 1904. 



July 2, 1904] 



MEDICAL RECORD. 



17 



Medical Record: 

A Weekly Journal of Medicine and Surgery. 



GEORGE F. SHRADY, A.M., M.D.. Editor. 

THOMAS L STEDMAN, A.M., M.D.. Associate Editor. 



PUBLISHERS 
WM. WOOD & CO., 51, Fifth Avenue. 

New York, July 2, 1904. 

COLLEGIATE TRAINING OF WOMEN. 
There has arisen among civilized women within the 
past few years a great desire to compete with men in 
whatever callings of life are open to both sexes. 
This new departure on the part of women has been 
especially noticeable in the United States. In order 
to qualif}- themselves to meet men on anythin.g like 
equal terms in the battle of life, women have rec- 
ognized the fact that they must, as far as is possible, 
be well equipped for the ira.y. Consequently female 
colle,ges have sprung up like mushrooms in all parts 
of this country. To a lesser extent this statement 
is true also of Great Britain. As to the wisdom of 
this course opinions are greatly divided, but the 
weight of evidence would seem to show that women 
in encroaching upon fields which have hitherto been 
occupied solely by men. on the whole, have been ill- 
advised. Of course, it is well understood that some 
women must go out of their own groove of work and 
earn their livings outside their homes. It is, how- 
ever, a grave question as to whether this tendency 
has not been carried to excess, and whether the race 
has not suffered, at any rate in America, through 
women deserting their domestic duties for a life 
which is contrary at least to the traditions of their 
sex. 

Is a collegiate training harmful to women? The 
rwajority of medical men are of the opinion that such 
is generally the case — at all events, that co-education 
is harmful to women — and hold the view that women 
are not fitted physically for the strain put upon them 
by strenuous professional or business careers. 

Inthe Edinburgh Medical JoitrualioTMaiy, 1904, Dr. 
T. Claj-e Shaw deals with this matter from his own 
point of view, which it may be asserted is probably 
the point of view of nine-tenths of the medical pro- 
fession. The writer points out that those best able 
to judge of the evils of college training for women are 
medical men attached to such institutions, and their 
experience is to the effect that stress of competition 
presses in too indiscriminate a way upon the young 
women who are brought together and educated in 
very large numbers. In the opinion of Dr. Shaw, the 
forcing system in vogue in colleges both for men and 
women at the present time is good neither for the 
quick-witted nor for the moderate or dull girls. 
The former, indeed, perhaps suffer the most, for 
their readiness at work and the pressure that is put 
upon them to accomplish an end at all risk, though 
at times compassed with impunity, often ends in 
disaster and evil after-consequences. The writer 
also thinks that the resiilts of these distressing efforts 
to compete with man on his own ground are de- 



cidedly barren. A few succeed in their university'' 
curriculum, and may be said to have found their 
true metier, but, in the words of Dr. Shaw, " It does 
seem as if the altruistic and sympathetic side of the 
woman's character is destroyed by the process of the 
new education, which substitutes a cold formalism 
for the warm spontaneity which dominates the 
majority of the sex." 

If women desire a university education they 
should be separated from men in their work, as in 
addition to the competition in intellectual pursuits 
the entire trend of co-education is toward the 
elevation of the pureh intellectual, and the disregard 
of the emotional side of the character, thereby un- 
fitting the woman for her natural vocation, that of 
motherhood and of caring for her children and 
home. While a few women succeed in competing 
with men on the same plane of mental endeavor the 
majority are more or less failures, their training on 
the lines of co-education, not having benefited 
them a jot, indeed rather the reverse. 

Dr. G. Stanley Hall, the eminent Americarr 
psychologist, has recently published a work on 
"Adolescence, " a part of which treats of its relations 
to education. In a consideration of adolescent" 
girls, and their education from a medical standpoint, 
the author quotes largely the opinions of medical 
men on the subject, some of which will be noticed 
here. Dr. Storer urged that girls should be educated 
far more in body and less in mind, and thought 
delicate girls frequently ruined in both body and 
mind by school. Dr. Clarke, in 1873, wrote a book in 
which he pleaded that woman's periods must be 
more respected. This work appeared at the height 
of the movement to secure collegiate opportimities 
for girls, and was suspected of being unofficially 
inspired by the unwillingness of Harvard University 
to receive them. It reached a seventeenth edition 
in a short time, but the views expressed therein were 
warmly combated by a number of ladies distinguished 
in the movement for the higher education of women. 
Clouston has, in various articles and books, ex- 
pressed himself in very trenchant terms. In the 
United States, Clouston thinks that most families 
have more or less nervous taint or disease; that 
heredity is weak because woman has lost her cue, 
althou.gh nature is benign and always tends to a 
cure if we have not gone too far astray, but, he adds, 
"There is no time or place of organic repentance 
provided by nature for sins of the school master. 
A man can work if he is one-sided or defective, but 
not so a woman. "If she be not more or less 
finished and happy at twenty-five, she will never be." 
Parents want children to work in order to tone down 
their animal spirits, and it almost seems to Clouston 
as if the devil invented school for spite. 

Dr. S. Weir Mitchell has so often given out his 
views on the question, that they are well-known. 
Woman, he holds, is physiologically other than man 
and no education can change her. Grant Allen said: 
"In any ideal community the greatest possible 
number of women must be devoted to maternity and 
marriage, and support by men must be assumed and 
not female celibacy. The accidental and exceptional 
must not be the rule or goal. This is only a pis 
allcr. It is not so much the unmarried minority 
that need attention as the mothers. We must 
not abet woman as a sex in rebelling against ma- 



i8 



MEDICAL RECORD. 



[July 



1 904 



temity, quarrelling with the moon, or sacrificing 
wifehood to maidenhood. " 

Le Bon pleaded that the education we now give to 
girls consists of instruction that fits brains otherwise 
constructed, prevents womanly instincts, falsifies 
the spirit and judgment, enfeebles the constitution, 
confuses their moods concerning their duties and 
their happiness, and generally disequilibriates them. 
Sir James Crichton Browne holds that differences 
between sexes are involved in every organ and tissue, 
and deprecates the present relentless zeal of inter- 
sexual competition, concerning the results of which 
it is apalling to speculate from a medical point of 
view. When the University of St. Andrews opened 
its theological department to women, it was not a 
retrograde movement, because our ancestors did no 
such thing, but a downhill step fraught with con- 
fusion and disaster. He quotes with approval 
Huxley's phrase that "what has been decided among 
prehistoric protozoa cannot be annulled by act of 
Parliament." Prof. A. W. Small thinks that to 
train women to compete with men is like poison 
administered as a medicine, the evils being quite as 
bad as the disease. 

So far as co-education is concerned, Dr. Stanley 
Hall thinks that while the system is not so harmful 
in college and still less harmful in universit}'' grades 
after the maturity which comes at eighteen or 
twenty has been achieved, it is high time to ask 
ourselves whether the theory and practice of 
identical co-education, especially in the high school, 
which has lately been carried to a greater extreme in 
this country than the rest of the world recognizes, has 
not brought certain grave dangers, and whether it 
does not interfere with the natural differentiations 
seen everjnvhere else. 

The consensus of expert opinion is against the 
higher education of women carried to extremes, and 
particular!}' adverse to co-education. The weighti- 
est argument against too much mental stimulus for 
women, is the fact that educated women, and 
especially highly educated women, are less fecund 
than their more ignorant sisters. Herbert Spencer 
was authority for the statement that "absolute or 
relative infertility is generally produced in women 
by mental labor carried to excess. " According to 
Dr. Hall, this has probably been nowhere better 
illustrated than by college graduates. He says 
"Excessive intellectualism insidiously instils the 
same aversion to 'brute maternity' as does luxury, 
overindulgence, or excessive devotion to society. 
Just as a man must fight the battles of competition, 
and be ready to lay down his life for his country, 
so woman needs a heroism of her own to face the 
pain, danger, and work of bearing and rearing 
children, and whatever lowers the tone of her bodv, 
nerves, or morale so that she seeks to escape this 
function, merits the same kind of opprobrium which 
society metes out to the exempts who cannot or who 
will not fight to save their country in time of need. " 
The ordinary' woman's true place is her home, and 
by far her most important duty to the race and to 
the State is the bearing and bringing up of children. 
Her educational training should at least not unfit 
her for the proper performance of this essential 
service. It is claimed, and undoubtedly with much 
truth, that the modem system of education does 
tend in this direction. Consequently, the system 



should be altered. If by a continuance of the 
present methods of educating women, the birth rate 
of those countries in which such methods are 
practised will inevitably decrease, it can be clearly 
understood that the game is not worth the candle. 



DIAGNOSIS OF TOPHI IN THE EAR. 
The differential diagnostic characters of tophi in the 
ears is discussed by Dr. Wilhelm Ebstein in a recent 
number of the Deiitsches Archiv fur klinische Mediziv.. 
Strangely enough, there seems, the author tells us. 
to be no very accurate description of tophi in the 
books. The question is then under what circum- 
stances one is justified in considering a nodule in the 
ear as referable to the group of tophi, and therefore 
proof of the existence of gout. The best description 
is that given by Garrod, who says tophi are some- 
times single, sometimes numerous, sometimes smaller 
than a pin head, sometimes larger than a split pea. 
The}' generally have the appearance of pearls, and 
usually lie on the borders of the helix. As regards 
consistency they are sometimes hard and sandy, but 
frequently soft and yield a milky juice on puncture. 
Since Garrod's time little in the way of description 01 
them seems to have been attempted. As to their 
significance, they are regarded as the exclusive 
property of the gouty. Thus Duckworth has found 
them in one-third of his cases (forty-nine out of 150). 
and as their appearance frequently precedes the 
arthritic manifestations of gout, their presence has 
acquired a diagnostic value that can hardly be over- 
estimated. 

In the course of the preceding year Ebstein has 
seen, in three cases, formations in the ears which 
resemble in many ways, and therefore . require 
differentiation from the true gouty tophi, from 
which they are separated by the following characters : 
First, their seat is neither in the cuticle, nor in the 
subcutaneous connective tissue, but in the cartilagi- 
nous tissue itself; and, secondly, no uratic contents 
can be obtained from them. The first of the cases 
was that of a man, with gradually increasing joint 
pains, and old tuberculous lesions at the apices, who 
presented on the antihelix sharply bounded, hemis- 
pherical elevations, 4 mm. in diameter, with a hard 
feel, which yielded on puncture no fluid, the tumor 
being solid. The left knee-joint was 3 centimeters 
larger in circumference than the right, and the 
patellar bursa contained fluid which was drawn three 
times but never contained uric acid or urates. The 
second case, a man of thirty-two, developed the 
tophi-like bodies while under intermittent ober\-a- 
tions extending over years. The helix and antihelix. 
tragus and antitragus, exhibited a series of promin- 
enceswhich.on puncture, yielded fluid not containing 
uric acid or urates. The mother was under treat- 
ment for chronic gouty arthritis. The third case 
was one of typical uratic gout, without typical tophi 
an}-where; prominences of cartilaginous consistence 
were present in the ear cartilage itself. 

These observations, though few in number, never- 
theless yielded a viewpoint that deserves attention. 
Grouped, the observations yield the result that 
rheumatic, and goutily-burdened individuals, tophi- 
like nodules mav be present in the ears which do not 
correspond to the gouty deposits frequently occur- 
ring there, not being like the ordinar}- tophi, seated 
in the subcutaneous tissue, but lying in the cartilages 



July 2, 1904] 



MEDICAL RFXORD. 



^9 



themselves. The\- appear to be generally of firm 
consistence, not deviating from that of the cartilage. 
Whether they bear a relation, and if so what relation, 
to rheumatism and gout, is an open question. This 
much, however, may at least be said, that in no 
case should one make a diagnosis of tophi, and there- 
from of the presence of gout, unless he obtains 
uratic contents from the ear tumors. 



Memorial to the L.\te M.wor Walter Reed. 

It is proposed to erect in the city of Washington, 
a suitable memorial to Walter Reed, Surgeon U. S. 
Army. For this purpose the Walter Reed Memorial 
Association has been formed and has further been 
incorporated under the general laws of the District 
of Columbia, to give unity to the various proposals 
which have been made for the securing of a Memorial 
Fund. The officers of the association are: Presi- 
dent, D. C. Gilman, LL.D., Vice-President, General 
G. M. Sternberg, LL.D; Treasurer, Mr. Charles L 
Bell; Secretary, General C. DeWiU. U. S. A. The 
executive, committee is composed of the following: 
Major L R. Kean, Surgeon, U. S. A.; Major W. 
D. McCaw, Surgeon, U. S. A.; and Dr. A. F. U. 
King. 

There are many and obvious reasons why the late 
Major Reed's memory should be perpetuated by the 
building of an appropriate monument. One reason 
is that physicians, whose benefits to the human race 
have been, perhaps, greater than those of any other 
profession, have been less often honored during 
life or after death than members of any other pro- 
fession. Again, medical men of the United States 
have not been greatly distinguished in original 
scientific research, so that when an American 
surgeon has made a discovery such inestimable 
importance as the cause of yellow fever, it is fitting 
that the discoverer should receive every possible 
recognition. 

Although Dr. Carlos Finlay of Havana, several 
3'ears ago, had advanced the theory that a mosquito 
convej^ed the yellow fever to man, he did not suc- 
ceed in demonstrating the truth of his theory. It 
remained for Major Reed to prove fully bylaboratory 
and practical experiments that such was indeed the 
case. The principal conclusions of the board of 
investigators, of which Reed was the leading spirit, 
were: (1) The specific agent in the causation of 
yellow fever exists in the blood of a patient for the 
first three days of his attack, after which time he 
ceased to be a menace to the health of others. (2) 
A mosquito of a single species, stegomyia fasciata, 
ingesting the blood of a patient during this in- 
fective period is powerless to convey the disease to 
another person by its bite until about twelve days 
have elapsed, but can do so thereafter for an in- 
definite period, probably during the remainder of 
its life. (3) The disease cannot in nature be 
spread in any other way than by the bite of the 
previously infected stegomyia articles used and 
soiled by patients who do not carry infection. 

The application of methods suggested by these 
conclusions resulted in the virtual extirpation of the 
yellow fever in Havana, and like means may be 
relied upon to have correspondingly efficacious 
effects in localities in which yellow fever is rife. 

It may be anticipated that it is but a matter of 
time when yellow fever will be known no more. 
That the discovery made by Reed is one of the 
first importance, must be clear to all. He was 
assuredly a benefactor to mankind at large, and as 
such his memory should be kept green. The medical 
profession throughout the country, military and 



civil alike, should haste to do honor to the name 
of Reed. 

Work of the Public Health and Marine-hos- 
pital Service. 
The annual report of the Surgeon-General, re- 
cently issued, gives the doings of the Marine-hospital 
Service for the fiscal year 1903. A part of the 
report is devoted to the sanatorium for consump- 
tives established by the service at Fort Stanton, 
\ew Mex. Two hundred and seventy-four pa- 
tients have been treated at the sanatorium during 
the year, an excess of 62 over the previous \-ear. 
There were 12 discharged, recovered; 54 discharged, 
improved; 10 discharged, not improved; 150 re- 
mained under treatment during the year. The 
treatment has been, on the whole, attended with 
very beneficial results, but as Surgeon P. M. Car- 
rington, the surgeon in charge, remarks, patients 
leave too soon. He thinks that greater control 
should be exerted over the patients in this respect. 
It is therefore suggested that Congress be asked to 
pass a law which will enable the service to enlist 
these patients for, say, a period of one year, or to 
make other written agreement with them, with 
appropriate penalty for breach of contract on the 
part of the patient, granting authority to the com- 
manding officer to arrest or otherwise restrain those 
desiring to leave without his consent prior to the 
termination of their enlistment or contract. 

Regarding the plague, the report states that cases 
of this disease have continued to appear in the Chinese 
district of San Francisco, thirty-eight cases being 
reported during the fiscal year. The aid afforded 
the municipal authorities has been continued, and 
this joint work has no doubt served to confine the 
disease to its original limits. No case of j-ellow 
fever was reported in the United States during the 
fiscal year 1903, while Cuba has continued to be 
free from the disease. 

Dviring the fiscal year 857.046 immigrants were 
inspected by the officers of the service as to their 
phj'sical fitness for admission, as prescribed by the 
immigration laws. One officer has been stationed 
at Naples, and another at Quebec, in the interest of 
the medical-inspection service. Examinations are 
conducted at thirty-two ports in the United States, 
and on account of the large number of immigrants 
entering at New York, Boston, Baltimore, Phila- 
delphia, New Orleans, and San Francisco medical 
officers have been assigned to dut}^ at these ports 
exclusively for the examination of arriving aliens. 

At the close of the fiscal year the commissioned 
corps of the service consisted of 109 officers, as 
follows: The surgeon-general, 6 assistant sur- 
geons-generals, 24 surgeons, 27 passed assistant 
surgeons, and 51 assistant surgeons. At the close 
of the fiscal year there were 179 acting assistant 
surgeons, including seven appointed for duty at 
fruit ports of Central America whose service will be 
terminated at the close of the quarantine season. 
During the fiscal year the scope of the hygienic 
laboratory has been increased with the additional 
features contemplated by the act of July i, 1902. 
The Division of Zoology has been organized and the 
organization of the Division of Pharmacology is in 
progress. The Division of Chemistry will be or- 
ganized at a later date. The work of the laboratory 
has been along lines pertaining to public health, 
examination of water supplies, a study of the action 
of various disinfectants and germicidal agents, 
the investigation of diseases and conditions of 
sanitary and economic importance. 

Among the contributed articles in the report is an 



20 



MEDICAL RECORD. 



[July 2, 1904 



excellent one by Passed Assistant Surgeon J. C. 
Perry on the epidemic of cholera in the Philippine 
Islands during 1902. 



The Localization of Tabetic Lesions. 
In the Paris letter of the Albany Medical 
Annals, for May, 1904, reference is made 
to Pierre Marie's article in the Revue Neu- 
rologiqtie on this subject. Marie's article is 
probably the best exposition of the matter that 
has ever been given. The Paris school of neu- 
rology has made immense studies of late, and our 
knowledge of nervous pathology has been greatly 
increased by the laboratory work of men like 
Brissaud, Marie, Babinski, and others. The meeting 
of the " Societe' Neurol ogique " on the first Thurs- 
day of every month is an event in scientific circles, 
for no meeting passes by withotit papers of the high- 
est interest being read and earnestly discussed. 

Marie, in his paper on "The Localization of 
Tabetic Lesions," proposed to explain this locali- 
zation, by bringing into play the h^mphatic dis- 
tribution of the spinal meninges. He has noticed 
that in early tabes, the topograph}' of the patches 
of sclerosis does not always coincide with the intra- 
medullary course of the posterior nerve-roots, 
and therefore thought that this relationship was 
more apparent than real. For him the sclerosis 
of the posterior columns is not the extension of the 
process observed in the posterior nerve-roots, but 
is dependent upon, and limited by, the lymphatic 
supply. From the investigations of several ob- 
servers and by laboratory experiments made by 
Marie himself and others, it is evident that the 
posterior columns, their meninges, and the posterior 
nerve-roots have a special lymphatic system, the 
"posterior lymphatic system," constituting in 
itself an anatomic entitj', Marie consequently 
believes that the lesions of locomotor ataxia can be 
best explained by admitting that the morbid process 
is one of h'mphatic origin and distribution. Marie 
ends his paper by saying that "The initial lesion of 
locomotor ataxia is a syphilitic lesion of the pos- 
terior spinal lymphatic system." 

The primary cause of tabetic lesions has ever 
been of the greatest interest to the neurologist. 
Recently a certain amount of doubt has been cast 
upon the widely held belief that to syphilis must 
be attributed the origin of locomotor ataxia. The 
conclusions therefore of so eminent a student of 
nervous pathology as Marie cannot but carry 
much weight. 

Military Sanitation in the Japanese Army. 
The Japanese have afforded to a somewhat wonderf 
ing world an excellent object lesson on the value o. 
military organization and preparation for war 
So well have they imitated and assimilated Western 
methods and ideas, that probably no European 
army is superior while more than one is inferior to 
that of Japan as regards equipment and organization. 
This is the case, too, with sanitary and medical 
affairs. The first evidence of the State of high 
efficiency to which the Japanese had brought their 
military medical organization was in the war with 
China in 1894. In the Journal of the Association of 
Military Surgeons of the United States for June, 
Lieutenant - Colonel John Van Rensselaer Hoflf, 
Deputy Surgeon-General, U. S. A., ctdls attention 
to this almost forgotten fact. The writer quoted 
from writings of the present Director General 
of the British Royal Army Medical Corps, who 
was at the time of the Chino-Japanese war at the 
scene of conflict. The then Colonel Taylor says 
in part: "At Port Arthur there were opportunities 



of seeingjhow every part of the medical machine 
worked. . . . Lives were saved on the spot where 
the men fell, by the prompt application of tour- 
niquet and even large arteries were ligatured under 
heavy fire. . . . The wounded were removed from 
the field without any delay just as quickly and quietly 
as they always were on the bi-weeklj- parades 
of the bearer columns in time of peace. If regi- 
ments were engaged far ahead, the regimental 
bearers did the work until the bearer companies 
came up, when they again took their places in the 
ranks. There was no loss of time, the medical 
men were ever)'where. " 

So little news of the war has been ailowed to leak 
out by the Japanese authorities that only the main 
facts are known. However, it may be taken for 
granted that the Japanese Military- Medical Depart- 
ment has upheld the reputation it gained for itself 
in the war with China, and has successfully vied 
with the army in fulfilling its duties. There is no 
doubt that if the war with Russia is long protracted 
that there will be an immense amount of disease 
with which to deal. When the rainy season sets in, 
considering the insanitarj^ state of the towns in 
Manchuria, typhoid fever will become rife, and 
it is not unlikely that plague and beriberi may 
attack the troops. Beriberi is a disease to which 
the Japanese are susceptible, and plague is a malady 
more prevalent in China than in any other country. 
The work before the medical organizations of both 
Russian and Japanese armies bids fair to tax 
their respective capabilities to the utmost, but, 
judging from the accounts of the Japanese Military 
medical service, it should, at least, be relied upon 
to cope with an}' situation presenting itself with 
credit. 

Nrhis nf the Berk. 

Medical Congress at St. Louis. — The plan and 
purpose of the Medical Department of the Congress 
of Arts and Science at St. Louis deviate so far from 
traditional lines that some explanation may be 
necessary to show how it should interest the medical 
profession. It is primarily a congress of scholars 
rather than of specialists. It is divided into 
twenty-four departments, one of the strongest of 
which is medicine. The Department of Medicine 
is divided into twelve sections, embracing the 
principal fields covered by the subject. These do 
not include Embryology. Anatomy, Physiology, or 
Bacteriology, as these subjects are embraced in 
in the Department of Biology. The Department of 
Medicine will be opened on Tuesday, September 
20, under the chairmanship of Dr. William Osier, 
with two general addresses by Dr. W. T. Council- 
man of the Harvard Medical College and Dr. 
Frank Billings of the Rush Medical College. One 
of these speakers will review the progress of medicine 
during the past centurj-, and the other will treat its 
fundamental conceptions. 

On Wednesday morning, September 21, a section 
of Public Health will meet under the presidency of 
Dr. Walter Wyman, Surgeon-General of the U. S. 
Public Health and Marine-Hospital Service. It 
will be addressed by Prof. W. T. Sedgwick of the 
Massachusetts Institute of Technology and Dr. 
Ernst J. Lederle, formerly Commissioner of Health 
of New York City. Communications relating to 
the subject are also expected from several eminent 
members of the profession. A section of Otology 
and Laryngology will meet at the same time: 
Chairman, Dr. Glasgow of St. Louis; Principal 
Speakers, Sir Felix Sermon of London and Dr. J. 
Solis-Cohen of Philadelphia. 



July 2, 1904] 



MEDICAL RECORD. 



21 



In the afternoon a section of Preventive Medicine 
will meet, under the chairmanship of Dr. Mathews, 
President of the Kentucky Board of Health. It 
will be addressed by Professors Ronald Ross of 
Liverpool and Celli of Rome. Some question has 
been raised against the advisability of separating 
the sections of Preventive Medicine and Public 
Health. This separation is, however, of no practical 
importance, as all interested may equally well 
attend both. On the same afternoon a section of 
Pediatrics will meet under the chairmanship of 
Dr. Rotch. and will be addressed by Escherich of 
Vienna, Jacobi of New York, and others. 

On Thursday morning, September 22, there will 
be meetings of sections of Pathology and Psychi- 
atry. The chairmen of these sections are Drs. 
Simon Flexner and Edward Cowles respectively. 
Marchand of Leipzig and Orth of Berlin have 
accepted invitations to address the section of 
Pathology, but it is not certain whether both will 
be able to attend. Psychiatry will be treated by 
Ziehen of Berlin and Dana of New York. 

In the afternoon a section of Neurology will meet, 
under the chairmanship of Prof. L. F. Barker of 
Chicago, and will be addressed by Kitasato of 
Tokio and Putnam of Boston. 

The sections which will meet on Friday and 
Saturday, September 23 and 24, are as follows: 

Therapeutics and Pharmacology. Chairman: 
Dr. Hobart A. Hare of Jefferson Medical College. 
Speakers: Sir Lauder Brunton, F.R.S., of London 
and Prof. Mathias E. O. Leibreich of the University 
of Berlin. 

Internal Medicine, Friday afternoon. Chairman: 
Prof. F. C. Shattuck of Harvard University. 
Speakers: Prof. Clifford Allbutt, F.R.S., of the 
University of Cambridge and Prof. William S. 
Thayer of Johns Hopkins University. 

Surgery, Friday morning. Chairman: Prof. Carl 
Beck of the Post-Graduate Medical School, New 
York. Speakers: Prof. Frederic S. Dennis of 
Cornell Medical College, New York, and one other 
not finally selected. 

ffj'wecoZogv. Saturday morning. Chairman: Prof. 
Howard A. Kelly of Johns Hopkins University. 
Speakers: Dr. L. Gustave Richelot, Meinber of the 
Academy of Medicine, Paris, and Prof. J. C. Webster 
of Rvish Medical College, Chicago. 

Ophthalmology, Saturday afternoon. Chairman: 
Dr. G. C. Harlan of Philadelphia, Pa. Speakers: 
Dr. Edward Jackson of Denver, Col., and Dr. 
George M. Gould of Philadelphia, Pa. 

One of the two principal speakers in each section 
will treat of the relation of the subject to other 
departments of knowledge; and the other of its 
present problems. Besides the principal speakers 
it is expected that each section will receive several 
brief communications from leading members of the 
profession in attendance at the meeting. It will 
be seen that the division into sections is one of 
subjects rather than of men. The chairmen and 
speakers will be different in different sections, but 
the attendance, it is expected, will be the same, 
except in the sections holding their meetings at the 
same time 

The California Medical Practice Law. — The 
Supreme Court of California has recently rendered 
a decision in a test case upholding the constitution- 
alitv of the law establishing the State Board of 
Medical Examiners. The decision not only declares 
the law constitutional in every respect, but approves 
of its object and affirms the need of such regulation 
of the practice of medicine in terms so emphatic 
as to effectualh" discourage all future attempts to 
evade the law. 



University of Southern Cahfornia.— The gradua- 
tion exercises at the Medical Department of the 
University of Southern California, Los Angeles, 
were held on June 14. The degree was conferred 
upon twenty-four members of the class. A most 
enjoyable banquet was participated in by the 
faculty, graduating class and alumni, at the Angelus 
hotel in the evening. On the following Thur'sday 
the corner-stone of a new clinical laboratory building 
was laid. This is to be one of the best equipped 
laboratories in the West and will cost $200,000. 

The Annual Sacrifice. — The New York Times says 
that the State Board of Health of Pennsylvania 
has communicated to the Mayors and Burgesses of 
every city and township in the State a memorandum 
calling attention to the need of a better enforcement 
of the law relative to the sale of toy-pistols and 
high explosives. It makes the assertion that the 
recorded casualties last year from the use of toy- 
pistols, giant firecrackers, and explosive toys 
during the Fourth of July celebration were 4,349 
injuries and 466 deaths, or more than the Russian 
casualties in killed and wounded during the recent 
two days' fighting at Hai-Cheng. Its tabulated 
record of injuries and deaths last Fourth of July 
makes the following showing of totals: 

Died of tetanus caused by injuries 406 

Died of other injuries 5^ 

Totally blinded jo 

Number who lost one eye - r 

Arms and legs lust ". -'^ 

Number who lost fingers 1-4 

Number injured who recovered 3.983 

Total number of casualties in the United States . . 4,349 

Warning against Yellow Fever.— Dr. Taber, the 
Commissioner of Health of Texas, has sent an 
official communication to the Governor requesting 
the latter to issue a proclamation warning the 
people of the State of the imminent danger of a 
yellow-fever epidemic if they neglect the first 
principles of cleanliness and sanitation in their 
houses and communities. On account of the open 
winter of 1903-4 in southern Texas and the prev- 
alence of yellow fever in Mexico at present, he 
says he greatly fears that should a case be introduced 
into the State with the present very bad sanitary 
condition of a large number of the cities and towns 
and the presence of the yellow- fever mosquito, 
which also exists in large numbers throughout the 
State, there will be the most extensive epidemic of 
yellow fever ever known. He therefore urges the 
Governor "to issue a communication calling upon 
the county judges, mayors, and health officers of 
Texas to inaugurate sanitary campaigns in every 
community in the State without delaj', especially 
for the destruction of the mosquitos." 

The Manhattan Eye and Ear Hospital, which has 
been located for many years at Forty-first Street 
and Park Avenue, is to have a new home next door 
to the Baron Hirsch Trades School in East Sixty- 
third Street. The capacity' of the present hospital 
is fifty ward patients, with eight rooms for private 
patients. It is proposed to construct eventually 
on the new plot buildings which will accommodate 
about four hundred ward patients and fifty private 
patients. 

Exhibit of Johns Hopkins Hospital at the World's 
Fair. — The Johns Hopkins Hospital has placed a 
display in the Educational Building at the St. 
Louis Exposition. It is unique as being the only 
demonstration of nursing work among the exhibits. 
The exhibit consists of a series of photographs 
showing the hospital' exterior, views of the interior, 
groups of student nurses at work in the labora- 
tories, class-rooms, and wards. Models of nursing 
appliances in operation, with specimens of charts, 



22 



MEDICAL RECORD. 



[July 2. 1904 



etc., are intended to give an idea of the opportunities 
for nurses and the results of their training. 

Sanitary Responsibility of Property Owners.— 
The Health Commissioner of St. Louis received a 
decision from the City Counselor in regard to the 
responsibility of agents, property owners, and 
tenants in cases in which insanitary conditions 
exist. The opinion of the Counselor states that an 
agent is never responsible e.Kcept in cases in which 
he has power of attorney; that where more than 
one family occupy the premises, if the tenants are 
compelled to use toilet facilities in common, the 
owner should be held responsible ; that if the prem- 
ises are occupied by more than one family and 
there are separate toilet facilities for each family, 
the persons using these accommodations should be 
held responsible for their sanitary condition, be 
they owner or tenant. 

An International Congress of House Sanitation. — 
The Societe d'Hygiene Franfaise has issued a call 
for an international congress to study the present 
hygienic conditions of dwellings and to devise means 
for their amelioration. The investigations and 
discussions of the congress will cover dwelling- 
houses in city and country, laborers' cottages and 
tenements, hotels, lodging houses, schools, and the 
living quarters on steam and sailing vessels. The 
work of the congress will be distributed among six 
sections, embracing the subjects above mentioned. 
The membership fee is fixed at 20 francs ($4). 
Those intending to present communications to the 
congress should forward the manuscript to the 
secretary -general not later than September i. The 
President of the congress is Dr. Janssen; the Secre- 
tarj^-General, Dr. F. Marie Davy, 7 Rue Brezin, 
Paris. 

First Toy-pistol Victim. — Walter Booth of Cin- 
cinnati was trephined June 25, at the City Hospital, 
for tetanus resulting from a toy-pistol wound. 
This is the first case in Cincinnati since the passage 
of the ordinance last March forbidding the sale of 
the toy-pistol. 

Cocaine Habit in Cincinnati. — Despite the fact 
that stringent laws were passed by the Ohio Legis- 
lature lastjwinter regulating the sale of cocaine, it is 
said that the sale of the drug in Cincinnati is larger 
now than ever before. It is sold principally on the 
levee and in the sections of the city where the 
dissolute congregate. It has been reliably estimated 
that 350 ounces of cocaine, of a value of about 
S6,ooo, is sold every month to this class in Cincinnati. 

National Guard of Pennsylvania.— Dr. Joseph K. 
Weaver of Norristown has been promoted from 
Division Surgeon to Surgeon-General, replacing Dr. 
Robert G. LeConte of Philadelphia resigned. Dr. 
George H. Halberstadt of Pottsville has been 
reappointed Surgeon of the Third Brigade, and Dr. 
T. C. Biddle of Ashland has been appointed 
Assistant Surgeon of the Eighth Regiment. 

Commencement Exercises of Rush Medical Col- 
lege. — This college, which is affiliated with the 
University of Chicago, held its commencement 
exercises June 15, at which time degrees were 
conferred on a class of 107. The Doctorate Address 
was delivered bv Dr. Chas. G. Stockton of Buffalo, 
N. Y. 

Increased Endowment. — The Chicago-Farmington 
Society held a lawn fete in Winnetka, 111., recently, 
at which $2,000 was raised to complete the endow- 
ment of the Sarah Porter room in the Passavant 
Memorial Hospital. 

Smallpox in Chicago. — Since the first of January 
there have been eightj'-nine cases of this disease 



discovered in Chicago, and removed to the Isolation 
Hospital, and it is said of these not a single individ- 
ual had been properly or recently vaccinated. 
Two patients died, seventy-six were discharged as 
recovered, and eleven were still under treatment. 

Dr. John B. Murphy was recently elected President 
of the Chicago Medical Society 

Hospital Needed. — Dr. Chas. E. Humiston of 
Austin, 111., urges the establishment of a hospital at 
some point midway between Austin and Oak Park. 
The two villages have a population of fifty thousand, 
a id the nearest hospital is four miles away. 

New Hospital at Kewanee, 111. — In the new St. 
Francis Hospital, Kewanee, organizations and 
individuals have already agreed to furnish twenty- 
one out of the twentj-'four private rooms. Dr. L. 
A. Westgate has decided to sell or close the Syca- 
more Hospital, which has not been a profitable 
institution. 

Physicians for Elks' Reunion. — Forty physicians 
have been appointed lur service during the Elks' 
Reunion to take place in Cincinnati this week. 
Thej- will serve without expense to the city, and 
will be uniformed in white with red crosses on 
sleeves. 

Dr. Russell Hulbert. — The report recently pub- 
lished in the daily press and in these columns that 
Dr. Hulbert had escaped from a sanatorium at 
Green's Farms and walked to Higganum, was 
incorrect. Dr. Hulbert had left the sanatorium 
and was at his parents' house in Middletown. 
One day fee walked from Durham to Higganum for 
the sake of exercise, and this was the only founda- 
tion for the report as published. 

Pulmonary Diseases in the Street-sweepers of 
New York. — Street Cleaning Commissioner Wood- 
bury made public a few days ago the result of his 
medical examination of the sweepers of the de- 
partment. He was aided in this work by ten 
physicians of the Health Department. Out of a 
total of 1,872 men 283 were found to be afflicted 
with pulmonary complaints. Of this number only 
60 had tuberculosis. The consumption scare in 
the Street Cleaning Department came about two 
months ago, when the department's doctors dis- 
covered that more than 25 per cent, of those who 
applied for sick leave were suffering from this 
disease. By the time the news reached the 
public it had taken growth, and the statements 
were made that a quarter of the entire street- 
cleaning force had consumption. The men be- 
came alarmed for their own safety, thinking that 
their work must be particularly dangerous, and 
their fears were not quieted by the discussion in 
the press of the peculiar dangers to which it was 
assumed they were exposed, despite the fresh-air 
theory of the prevention and cure of the disease, 
r. Obituary Notes. — -Dr George L. Fitch, a native 
of New York State and of late a resident of San 
Francisco, died suddenly at Santa Cruz, Calif., on 
June 2. From 1880 to 1885 Dr. Fitch served as 
the Crown physician of Hawaii. In this capacity he 
made a study of leprosy on Molokai. 

Dr. Ch.'VRLES S. Woodw.^rd of thiscity died at 
Glens Falls on June 26, of pulmonary tuberculosis. 
He was bom in Michigan thirty-five years ago, 
and was graduated from the Xew York Univer- 
sity Medical School in the class of 189 1. He was 
a member of the New York State Medical Associa- 
tion. 

Dr. Jons- F. Bird died a* Fox Chase. Philadelphia, 
on June 23. at the age of eighty-nine years. He 
was graduated from the Medical Department of 



july 2. 1904] 



MEDICAL RECORD. 



23 



the University of Pennslyvania in the class of 1843. 

Dr. Julius J. Strecker died at Johnstown, Pa., 
on June 23 at the age of fifty-three years. He was 
graduated from Jefferson Medical College in the 
class of 1878. He was President of the Board of 
Health of Cambria County and Vice-President of the 
Cambria County Pharmaceutical Society. 

Dr. Dennis J. Tre.icy died in Philadelphia on 
June 20 at the ageof sixty years. He was graduated 
from Jefferson Medical College in the class of 1867. 

Dr. James Simpson died in Philadelphia on June 
20 at the age of sixty-five years. He was a student 
at Jefferson Medical College when the Civil War 
broke out, receiving appointment as an Army 
Surgeon and being placed in charge of the hospital 
corps at Alexandria, Va. At the close of the war 
he concluded his medical studies and was graduated 
from Jefferson College in the class of 1865. He was 
for several years chief physician to St. Mary's Hospital. 

Dr. J.'iMES M. Clement died of pneumonia in 
Philadelphia on June 12, at the age of seventy-one 
years. He was graduated from the Medical Depart- 
ment of the University of Pennsylvania in the class of 
1862. 

Massage of the Heart for Chloroform Collapse. — W. W. 

Keen states that on only three occasions in his entire profes- 
sional life has he had a patient die on the table. The first 
two were cases of operations on the brain and goiter 
respectively. Hemorrhage was the cause of death in 
both cases, all the usual means being unavailing. The 
third case was especially interesting for several reasons. 
This patient had previously had a fracture of the skull 
from which he had entirely recovered. He later suffered 
from squamous epithelioma of the vocal cords. At the 
first operation unilateral laryngectomy was performed, 
partly under local ansesthesia and partly under chlorofortn. 
The latter produced marked cyanosis. At the second 
operation, total laryngectomy was performed. Chloro- 
form and oxygen were given to the patient, but not until 
he was upon the operating table. When enough chloro- 
f rm was given to keep him quiet he became so cyanosed 
as to make the writer very anxious for his life. Just as 
the wound was ready to be closed his pulse suddenly failed 
and his face became suddenly blue. The operation : nd 
the administration of chloroform were immediately 
stopped. Strychnine was given hypodermically, pure 
oxygen was administered, and artificial respiration was 
instituted with rhythmical traction on the tongfue. The 
battery was applied over the phrenic, but in spite of all 
this treatment, his heart continued to beat much faster 
and weaker; he became more cyanotic, and in two or 
three minutes he was dead. After continuing the above 
means for about ten minutes as a last resort the upper 
abdomen was opened and the writer introduced his hand 
into the abdominal cavity, and between this hand and the 
right hand, which made counter-pressure on the anterior 
wall of the chest, the heart was massed. These efforts 
were continued for nearly half an hour, but without 
avail. The writer then reports a case which came under 
Igelsrud's care. The operation was that of abdominal 
hysterectomy. There was chloroform collapse. The 
writer laid bare the heart by a resection of parts of the< 
fourth and fifth ribs. The pericardium was opened and 
the heart seized between " he thumb and fore and middle 
fingers on the anterior and posterior surfaces. Strong and 
rhythmical pressure was made for about one minute when 
the heart began to pulsate of itself, but as the pulsations 
became weaker, massage of the heart was practised for 
about one minute more. From that time the pulse was 
perceptible and the contractions of the heart became 
regular. The patient recovered. The writer gives an 
interesting resume of work by various authorities on this 
subject. — Proceedings of the Philadelphia County Medical 
Society, March 31, 1904. 



OUR LONDON LETTER. 

(From Our Special Correspondent.) 

HOSPIT.\L SUNDAY SPONGE LEFT IN ABDOMEN, ACTION 

FOR DAMAGES CENTRAL MIDWIVES' BOARD'S ABSURD- 
ITIES — DIRECTOR-GENERAL NAVAL MEDICAL DEPART- 
MENT — king's college HOSPITAL TUNBRIDGE WELLS 

HOSPITAL NURSING ASSOCIATIONS — L. L. JENNER. 

London, June ir. 1904. 
We are on the eve of Hospital Sunday, and great efforts 
are being made to equal and, if possible, to surpass the 
last year's collection. That was the record year (,464,- 
975). Some hope to make it £"100,000 this year. Mr. 
George Herring has again promised to add one-fourth to 
the amount collected up to £100,000. Last year his 
cheque was £12,302. The Lancet has again issued a 
special supplement for distribution, and the Lord Mayor 
has made the usual appeal. Mr. Charles Morrison has 
sent in £1 ,000 to be added to the fund. 

An action against a lady doctor was concluded on 
Tuesday in a way which seems fraught with serious 
consequences for the profession, while it controverts 
the received doctrine of negligence. A patient, on 
whom the doctor had performed an abdominal opera- 
tion, brought the action for damages in consequence 
of a sponge having been left behind. The judge, in 
summing up, said there was no doubt that the oper- 
ator was a skilful surgeon, but the question was 
not as to her skill but whether she had been guilty of 
want of reasonable care. He put the following questions 
to the jury: (i) Was the defendant guilty of want of due 
and reasonable care in respect of the counting or superin- 
tending the counting of the sponges? (2) Was the nurse 
employed to act as defendant's assistant during the opera- 
tion.' (3) Was the nurse guilty of negligence in counting? 
(4) Was the counting of the sponges a vital part of the 
operation? (5) Was the nurse under the control of the 
doctor during the operation? The jury after a long de- 
liberation, answered all five questions in the affirmative 
and assessed the plaintiff's damages at one farthing. 
The judge pointed out that this was inconsistent with the 
findings on the other questions and the jury again retired 
to consider that point. On returning they said they did 
not think this was a case for damages, as the operation 
had been performed by the defendant without any fee. 
Finally, they declared plaintiff ought not to have more 
than £25, and that only in consideration of her suffering. 
Judgment was accordingly entered for that amount and 
costs. 

Several questions are being talked about in reference 
to this case. It seems to traverse the general view that 
professional service is not to be accounted as negligent 
if ordinary skill and care be exercised. Special or expert 
skill is not the oft'er of the ordinary professional man. 
It is not improbable that much discussion on this point 
will take place. 

Another question arises as to the liability of a doctor 
who renders a service without fee or reward. Should a 
patient who accepts gratuitous aid have a right to dam- 
ages for unskilful or negligent treatment? If this is 
to be recognized as law, surgeons will become more chary 
of taking such cases, or may think it necessary to protect 
themselves by obtaining an indemnity beforehand, in 
case of a mischance occurring. 

It would seem that those who leave counting sponges 
to the nurse are yet responsible for her errors — a decision 
which may serve to check the tendency to hand over to 
nurses duties for which they are not fitted. This applies 
to many points in practice. If a miscount by a nurse 
is to saddle the doctor with damages, the position becomes 
more serious. 

Another point was raised in a conversation the other 
day, VIZ., was the doctor in this case a member of one 
of the protection societies? Some said if not, she did 
not deserve pity. For ten shillings a year a kind of 
insurance can be entered into against the pecuniary 
consequences of such a misadventure. The defence 
would be undertaken by the society of which the doctor 
was a member, and would probably be more successful 
than when conducted by lawyers, without special experience. 

The last question reminds one that the annual meeting 
of the Defense Union was held on the 26th ult.. when 
a very satisfactory report was presented. In the past 
year over 1,000 cases had been submitted for the council's 
consideration, besides many others which had been dealt 
with by the secretary. This shows the great risk that 
is run by practitioners in various ways. The cases that 
go to the solicitor are about 150 per annum. Some 
remarkable statements were made as to attempts at black- 
mail defeated by the intervention of the union, and 
of slanders or libels retracted and apologized for as soon 



24 



MEDICAL RECORD. 



[July 



1904 



as the accusers found the defence^iWasjh the hands of a 
society. 

The proposal of the British Medical .Association to 
absorb the Defence Union was repudiated, and the meet- 
ing determined to "maintain the integrity of the union 
in its entirety as at present existing. " . „ , 

You know how the apathy of the profession allowed 
the Midwives' Act to pass — an apathy which many now 
lament. The Central Midwives' Board— the product of the 
act— has now resolved to invite rep rters to its meetings. 
This is, so far, well, for hitherto the proceedings of the 
board have been characterized by ignorance and prejudice. 
So much so that Dr. W. J. Sinclair of Manchester, an 
independant member of the board has felt constrained 
to expose some of its doings. This eminent professor 
accepted a seat, but has not been able to secure the co- 
operation of the other medical members, and as a con- 
sequence the lav members have utterly ignored the 
profession — or rather, so far as they can, placed it in 
a position of inferiority to the midwives' calling. Thus, 
they have actually prop'osed to appoint a "trained woman" 
as an inspector of institutions applying for recognition. 
That such inspection would be useless, that it would be 
an insult to the medical staffs and, through them, to the 
whole profe«ion to sertd a midwife to report on their 
teaching, was of no consequence. The n>idwife interest 
carried it — and that because three out of four medical 
members, to their shame be it said, declined to vote 
At the next meeting the degradation of the profession 
is to be carried a step further by a proposal to appoint 
matrons or midwives of lying-in hospitals as examiners. 

Many coimty councils have appointed their medical 
officers" of health as executive officers for the adminis- 
tration of the act. How will these M. O. H.'s, most of 
them highly qualified practitioners, relish the idea of 
their work "being inspected by midwives or their teach- 
ings reported on bv matrons? 

You will reme'mber how this board lately pro\-ed 
its incompetence by refusing to recognize the Dublin 
Schools of Obstetrics, which are notoriously the 
most efficient in these islands and perhaps in Europe. 
At the same time the London Obstetrical Society's 
diplomas were recognized as also a numljer of institutions 
\\-ith no pretense to be more than local lying-in charities 
But the board has now capped all its former exploits by 
a resolution that "it is desirable that Mrs. H — — should 
be certified, as it appears from her letter that she is quite 
prepared to take a case alone." This woman's letter 
stated "that she had not undertaken cases without doctors, 
but had been advised by a medical man that she need not 
be afraid to do so and she did not feel afraid of so acting. 
•The resolution is in direct defiance of the board's onvn 
rules, and will serve as a precedent for any woman cer- 
tifying herself as not afraid to act as a midwife. 

All this scandal arises, as I have said, from the apathy 
of the mass of the profession and the readiness of a few 
men-midwives' to sacrifice the interests of their brethren 
to the "Midwives' Institute, " a small trades-union of Mrs. 
Gamps. 

Inspector-General Herbert M. Ellis, R. N., has been 
selected to succeed Inspector-General Sir H. F. Xorbury, 
K.C.B., who will shortly retire, as Director-General of 
the Navy Medical Department. 

The Duke of Connaught has accepted the presidency 
of King's College Hospital in succession to the late Dulce 
of Cambridge. 

Last night there was a grand fancy ball at the Albert 
Hall on behalf of the removal fund. It was organized 
by the Countess of Pembroke, and a large number of the 
smart set attended and a great success was attained. The 
peculiarity proposed and largely carried out was for the 
ladies to adopt a fancy head-dress. 

Tunbridge Wells Hospital has been enlarged at a cost 
of £25,000. The new buildings comprise male and female 
wards of twenty-four beds each, children's ward, isolation 
ward, and additional out-patients' accommodation. Ten 
thousand pounds has been raised and a bazaar was 
opened on Tuesday in aid of the fund. 

The report of the Affiliated Benefit Nursing Asso- 
ciations for the Supply of Cottage Xurses, presented at 
the annual meeting on Wednesday, stated that 138 societies 
are now comprised in the organization, that the balance 
sheet is satisfactorj-, and that the demand for the benefits 
of the association is increasing. 

The Colonial Nursing Association's annual meeting 
on Wednesday was graced by the presence of Princess 
Henry of Battenburg and a distinguished company. 
Mr. Chamberlain was among them, and a reprint of his 
article in the North-American Review was distributed. 
This association has 109 nurses at work, 89 haxing been 
selected at the request of the government. Earl Grey 
said the association was filling the r61e and almost the 
dignity of a department of State and deserved the support 



of every public-spirited individual. The Duke of Marl- 
borough added that the Colonial office constantly received 
evidence of its usefulness. 

The first annual report of Lady Dudley's scheme 
to establish district nursing in the poorest parts of Ireland 
has just appeared, and in a rather attractive form. There 
are photographs of the districts where the nurses are at 
work. Nine nurses have been placed in cottages, or in 
lodgings in poverty-stricken places, and are doing a great 
work in ministering to the suffering poor. To extend the 
system only funds are needed, and for such help the com- 
mittee appeals. 

The death of Louis L. Jenner. M. B. O.xon.. of the Lister 
Institute of Preventive Medicine, at the early age of 
thirty-eight, occurred on the 2d inst. He was the fourth 
son of the late Sir William Jenner, Bart., G.C.B. 



OUR LETTER FROM THE PHILIPPINES. 

(From Our Special Correspondent.) 

SANITARY PROBI.BMS NEED OF AN EFFICIENT PERSONNEL 

LACK OF FUNDS — lo.N'ORANCE OF THE NATIVES — OPPO- 
SITION OF THE LANDLORDS OUTLOOK PROMISING DE- 
SPITE OBSTACLES. 

M.\KiLA, May 26, 1904. 

The question of an efficient personnel for the execution 
of sanitan,' work is a very troublesome one. The number 
of available physicians is totally inadequate to meet medi- 
cal and sanitary needs, and there are some four hundred 
municipalities in the islands having organized governments 
which have no local boards of health, for the reason that 
there is not a single physician or undergraduate in medi- 
cine living in any one of them. Clearly, without the 
advice of any medical man being available, any efforts at 
local sanitation in such towns must be inefficient, and 
proper statistics as to causes of mortality will be unobtain- 
able. This deficiency in the number of medical men is one 
that can only be remedied by the education as physicians 
of a much larger number of young men than are now 
matriculating at the single medical school in the islands; 
the best that can be done to minimize the evil effects of 
such deficiency is to cause frequent inspections to be made 
of towns having no such boards of health by provincial 
and insular health officers. A higher standard of medical 
education should also be required. Xot a few of the native 
physicians present marked professional deficiencies, not so 
much through their own fault as through the absence of 
modem facilities for their education. Manila is the only 
place in which there is a sufficiency of doctors, but there is 
no small difficulty in inducing these to take positions in 
the provinces, where they would be surrounded by a pop- 
ulation regarding them with more or less distrust as for- 
eigners and with whom they would have little that is con- 
genial. For the minor sanitary positions there is less diffi- 
culty in securing satisfactory service, for the Filipino leams 
his part readily in the performance of routine and can 
carry out directions even when unable to initiate the 
proper action in an emergency. One trouble with this class 
of minor employees is that they are too apt to assume 
undue importance in their official positions and commit 
abuses liable to bring the whole sanitary service into dis- 
repute. The employees of all grades, as a whole, require 
frequent inspection to keep them up to the efficient per- 
formance of a reasonable amount of work. In any medi- 
cal emergency of any importance in the provinces, assist- 
ance and supplies must usually be sent to the local author- 
ities from Manila, subject to the common annoying delays 
due to poor transportation facilities and deficient means 
of communication. 

Another obstacle to health work is lack of funds. The 
proportion of the appropriations allotted to this purpose is 
satisfactory, but with the inception C)f sanitary work it 
was found that the investment of a vast amount of money 
in permanent sanitary improvements was necessary. 
Nothing of a sanitary nature was inherited from the Span- 
iards. In spite of the desire to limit outlay, many changes 
were imperatively demanded, and in Manila alone the 
attempt to convert it into a modem city, from one of the 
sixteenth century, in the brief space covered by the Ameri- 
can occupation, would have bankrupted the inhabitants. 
Sanitary growth in other parts of the world is gradual, 
while here proper sanitation meant a complete remodeling 
of everything done up to that time. Tasks must be under- 
taken as a whole which in other countries would simply be 
continued over long terms of years. With a country left 
impoverished bv war and pestilence, the revenues were 
naturally unsatisfactory and the appropriations for sani- 
tary purposes suffered accordingly. The only remedy 
available is found in greater financial prosperity, and in 
the time necessary to accomplish the sanitary changes 
required. 

Ignorance is a great bar to sanitary work. A large part 
of the population is illiterate, and some 600,000 of them 



July 2. 1904] 



MEDICAL RECORD. 



-3 



are savages. The amount of assistance in sanitary work 
which would be given by naked, head-hunting, and ghost- 
worshiping savages is naturally not great. It is useless 
to appeal to their intelligence and reason from the basis of 
modem medical science, for the latter is absolutely 
unknown to them and totally opposed to tribal teachings 
and customs. Even among the more intelligent Filipinos 
it is difficult to make many understand that sanitary sci- 
ence is based on accurate knowledge; they are unwilling 
to disinfect in cholera because they cannot see the bacilli, 
yet they pray for relief from the epidemic to an invisible 
San Roque. One great reason for ignorance on sanitary 
matters is the total absence in the past of any literature 
on the subject in the native languages, the lack of any 
such information in Spanish and the failure on the part of 
the Spaniards to give any instruction in such matters. 
Here a great opportunity is afforded for the inception of 
a sanitary educational propaganda, through the wide cir- 
culation of bulletins on health matters couched in simple 
language and printed in the various native tongues, and 
through the teaching of elementary hygiene throughout 
the public schools. Such an educational propaganda, effi- 
ciently conducted, should bring about more iinmediately 
satisfactory results than could be obtained in any other 
way, and is the best means of advancing sanitation at the 
present time. The board of health is already proceeding 
along these lines, both by the education of health officers 
in a practical school in Manila and the circulation of a 
vast amount of literature on health matters. 

In Manila the chief objections to sanitary' work now 
come from the wealthy householding class, who are unwill- 
ing to pay the bills for the sanitary remodeling of their 
unwholesome tenements. These bills have been very 
heavy, as naturally would be the case in a city where prac- 
tically everything was wrong from a sanitary standpoint. 
This wealthy class has fought sanitary reform in every pos- 
sible way, and has only lately come to the conclusion that 
compliance is necessary and that sanitary laws were made 
to be enforced. The poorer classes have lately come to 
understand that these sanitary reforms are much to their 
advantage and mean greater comforts and conveniences 
of life for them. A noticeable change has lately occurred 
in the much greater frequency with which these people are 
calling the attention of the sanitary authorities to unhy- 
gienic conditions, and requesting their abatement. The 
working classes are rapidly learning that health is their 
most valuable asset, and the householding class that an 
insanitary tenement is not a good investinent. 

On the whole, sanitary work here has every drawback 
met with in civilized communities, besides many obstacles 
of which the sanitarj- officer in the United States has no 
conception, and the importance of which can only be appre- 
ciated through extended personal experience. Neverthe- 
less, the outlook for considerable sanitary progress in the 
early future is very promising. As far as the provinces go, 
sanitary advance must depend to a considerable extent 
upon commercial development and prosperity and the 
higher type of general civilization attached thereto. 
Ignorance and superstition are to be combated by educa- 
tion, racial dislike overcome, and distrust superseded by 
confidence. The guiding hand should be firm, yet diplo- 
macy will be required and important sanitary problems can 
never be considered as apart from politics. The Filipino 
is readily susceptible to kindly handling, and a little tact 
and consideration will remove opposition that force could 
not brush aside. Many reforms cannot be carried out in 
an ideal manner; under such circumstances one must be 
contented with the best results which it is possible to 
obtain. Continued opposition along any given line is best 
met by temporary cessation of pressure until the people 
have become accustomed to the new order of things, when 
the advance may be resumed. Larger funds for sanitary 
expenditure will be available as the country recovers from 
the effects of war and epidemic, while experience will add 
to the efficiency of the sanitary personnel. Nevertheless, 
it is too much to expect that provincial conditions here 
will at any early date approach those of rural communities 
of the same size in the United States. With the exception 
of Japan, however, it is equally true that another decade 
should see provincial conditions here better than in any 
other part of the Orient. With regard to the city of 
Manila, sanitary improvement should be even more rapid. 
Much is now being done in the way of house repairs, grad- 
ing, draining, filling, and the opening up of new means of 
communication. Work is shortly to be commenced on the 
new water supply, and it, with the drainage and sewerage 
S5'stems already planned, should be completed within three 
or four years. Cholera has been banished, plague cut 
down, and special attention given to the infant mortality. 
The health work is constantly being broadened as oppor- 
tunity offers and funds permit. In view of all this, there 
is no reason why Manila shall not share with Havana the 
honor of feeing the healthiest citj' in the tropics, and show 
a lesser mortalitv than manv communities at home. 



ELECTRICITY APPLIED TO THE DENUDED 
PERICARDIUM OVER THE VENTRICLE IN 
HEART FAILURE: A SUGGESTION. 

To THE Editor op the Medical Record: 

Sir: As a possibly successful means of resuscitation in 
sudden heart-failure I would suggest laying bare the 
pericardium over the left ventricle and applying electricity 
at the bottom of the wound. 

The usual failure of electricity applied over the pra- 
cordium to excite cardiac action is probably due in large 
part to the very .great electrical resistance of the in- 
tegument and the subcutaneous fascia characteristic of 
those structures. This resistance dissipates the current 
through a wide area, and necessitates such intensitv of 
action as endangers deeper-lying nerve centers. With 
onlv the two layers of the pericardium between the 
electrode and thecardiac muscular fiber it should be easy, 
theoretically at least, to provoke contractions by a rela- 
tively feeble current, particularly if concentrated upon a 
limited area by the use of a small electrode. 

Moreover, the possible importance of this power of 
Hmiting and controlling the action -nail be apparent whin 
we consider the possibly disastrous effect of including the 
inhibitory nerves in the'electric stimulation. 

As a "last resort, electric-puncture nto the muscle 
substance might be tried, the surface of the heart being 
practically already exposed. Incidentally there would 
be an advantage in being able to note slight ventricular 
movements, of which there would be no indication if the 
chest-wall were intact. 

Andrew H. Smith, M.D. 

18 E.\sT Forty-sixth Street. \ew York. June 20. 1904. 

THE PRESENT STATUS OF THE SURGICAL 
TREATMENT OF CHRONIC BRIGHTS DIS- 
EASE. 

To the Editor of the Medical Record. 
Sir: An article bearing the above title, from the pen 
of Dr. A. A. Berg, which appears in the issue of yoiir 
valued journal of June 18, has interested me. In this 
article the writer engages in the laudable attempt to base 
the indications for "medical and surgical therapy upon 
the variety of nephritis present. For this purpose he 
arranges all cases of nephritis according to their etiology, 
under eight groups. As illustrating types of these groups. 
Dr. Berg details six cases ; three of his own, two of Rovsing 
and one reported bv the writer. A few not unimportant 
errors have crept into the report of the case last named; 
to correct these is the purpose of the present communi- 
cation. . , , ... 

Dr. Berg writes: "As evidence of the bacterial m- 
fection producing different lesions in the kidneys of the 
same patient, the following history is quoted from Ede- 
bohls : In the one kidney are all the evidences of chrome 
Bright's disease, in the other multiple abscesses." Now, 
as a matter of fact as well as of record, both kidneys 
were the seat of chronic Bright's disease, and both kidiieys 
were, in addition, affected by pyelonephritis with miliary 

Next follows an abstract of the history of my case as 
originally reported in full in the Medical Record of 
December 21, 190 1. In the course of his abstract. Dr. 
Berg states: "After the operation (right nephrectomy) 
the patient's condition improved, and she gained flesh 
and strength, but her urine contained albumin and casts 
Gradual evidences of chronic Brighfs disease developed 
and Edebohls performed decapsulation on the remaining 
kidney." This again is a misunderstanding on the part 
of Dr. Berg possibly due to hurried or careless reading 
of mv original report, where it is distinctly stated that 
the nephritis from the patient's last pregnancy, while 
infection of both kidneys occured only sometime after 
delivery. In other words, the case represented an in- 
stance of bilateral chronic parenchymatous nephritis with 
subsequent infection of both kidneys. The order of 
events was as follows: Chronic nephritis during entire 
last pregnancy, which terminated at tefm on tebruary 
12, 1901. Persistence of chronic nephritis after delivery 
Hysterectomy for sloughing uterine fibroma, March 17 
1 90 1. Acute" proteus infection of right kidney a month 
later. Right nephrectomy for acute pyelonephritis w^ith 
miliary abscesses. July 9, 1901- Persistence of left 
chronic nephritis and of pyuria. Decapsulation of left 
kidney, November 10. 1901. t c 1 

While the above errors are perhaps explicable, 1 hr I 
it difficult to account for the following statement of Dr. 
Berg, on page 996: "Edebohls' case (cited above) of 
bilateral bacterial nephritis in which one kidney w-as 
removed and decapsulation performed upon the remain- 
ing one, was only temporarily improved, the patient finally 
succumbing to the disease." Not only has she not sue- 



26 



.MEDICAL RECORD. 



[July 2, 1904 



cumbed, but at the present wriling, more than two years 
after decapsuJation of the kidney, the patient is in the 
enjoj'ment of practically perfect health. This gratify- 
ing state of afiEairs has been reached after stead}' progress 
toward health during the past two years, a progress 
apparently continuous even at the present time. A trace 
of albumin, with a very occasional hyaline cast and 
leucocyte, are all the indications that remain of her former 
serious condition, while the patient has long ago resumed 
her duties in hfe, has absolutely no complaints of any 
kind, and considers herself a perfectly well woman. 

I am possibly as deeply interested as any physician or 
surgeon in the solution of the problems of the surgical 
treatment of chronic Bright's disease. Articles of the 
scope and aims essayed by Dr. Berg are particularly 
welcome and appreciated, especially if based upon per- 
sonal experience, as is the case in part at least in the 
present instance. So much keener is the disappointment 
when the validity of deductions and conclusions made and 
drawn are practically nullified by the incorrectness of 
the premises upon which they are based, and especially 
when such mistakes in the premises might, as in the 
instance before us, have been so readily avoided. 

Whether other avoidable errors have crept into Dr. 
Berg's paper I am not prepared to say. Of imavoidable 
errors, that is, errors into which Dr. Berg's personal 
experience has perhaps not been sufficientl}' large or 
varied to prevent him from falling, I have noted one or 
two which I may attempt to correct in the proper place 
on a future occasion. George M. Edebohls, M.D. 

New York. 

THE XATIOXAL ASSOCIATIOX FOR THE 
STUDY AND PREVENTION OF TUBERCU- 
LOSIS. 

To THE Editor op the Medical Record: 
Sir: I am in receipt of a number of inquiries from all 
over the United States and from abroad, concerning the 
outcome of the various meetings which have taken place 
in Baltimore, Philadelphia, New York, and Atlantic 
City in regard to the formation of a national tuberculosis 
association. Although your paper published a para- 
graph concerning the Atlantic City meeting, it must have 
escaped the notice of many of my correspondents. 

The constitution and by-laws of an American National 
Association for the Study and Prevention of Tuberculosis 
were adopted on Monday, Jime 6, at Atlantic City. The 
objects of the organization, as stated in its constitution, 
are as follows: (a) The study of tuberculosis in all its 
forms and relations; (6) the dissemination of knowledge 
concerning the causes, treatment, and prevention of tuber- 
culosis; (c) the encouragement of the prevention and 
scientific treatment of tuberculosis. 

The following arc the officers of this association : Presi- 
dent, Dr. Edward L. Trudeau of Saranac Lake, N. Y.; 
Vice-Presidents. Dr. William Osier of Baltimore and Dr. 
Hermann M. Biggs of New York; Treasurer, Dr. George 
M. Sternberg of Washington, D. C; Secretary, Dr. Henry 
Barton Jacobs of Baltimore. The Board of Directors, in 
addition to the officers above named, consists of Drs. Nor- 
man Bridge, S. E. Sollv, John P. C. Foster, Arnold C. Klebs, 
Robert H. Babcock. J. N. Hurtv, Wm. H. Welch. H. B. 
Jacobs, John S. Fulton, Henrv M. Bracken, Wilham 
Porter, Edward O. Otis, Vincent Y. Bowditch, Frederick 
L. Hoffman, S. A. Knopf, Edward T. Devinc, Charles L. 
Mmor, Charles O. Probst, Lawrence F. Flick, Mazyk 
P. Ravenel, H. S. Anders, Leonard Pearson, M. M. 
Smith, George E. Bushnell, and Walter Wyman. 

Its membership is to consist of three classes; (a) Mem- 
bers — those who are elected by the Board of Directors 
and who pay annual membership dues of S5. (b) Life 
members — those who pay $200 and are already members 
of the association, (c) Honorary members — persons dis- 
tin.cruished for original researches relating to tuberculosis, 
emmcnt as physicians or as philanthropists, who have given 
material aid in the study and prevention of tuberculosis. 

The government of the association, the planning of 
work, the arrangement for meetings and congresses, 
and everything that appertains to legislation and direction, 
are to be in the hands of the Board of Directors, and 
committees are to have the power to execute onlv what 
IS d reeled by the board. The Board of Directors is 
empowered, however, to appoint an executive committee 
of seven members to which is entrusted the executive 
work of the association. This committee, chosen at 
the meeting in Atlantic Citv, consists of Drs. Edward 
L. Trxideau, Henry Barton Jacobs, Edward O. Otis. Mazvk 
P. Ravenel, Arnold C. Klebs, John N. Hurty, and Mr. 
Edward T. De\'ine. The Board of Directors s em- 
I^owered to appoint representatives to the International 
Lommittee on Tuberculosis. It was decided at the 
meetrag of organization, that this representation was 
to be headed by Dr. Wm. Osier, and his associates will 
be selected later. The board is authorized, also to 



appoint such committees as maj' be necessary for scien- 
tific and educational work, and for the holding of meet- 
ings and congresses. 

The majority of the vast audience present at the 
Atlantic City meeting were enrolled as members of the 
new organization. S. A. Knopf, M.D. 

16 West Ninety-fifth Street, Xew York. 



THE POTASSIUM CHLORATE AND IRON 
MIXTURE. 

To THE Editor of the Medical Record: 
Sir: Permit me to make a few remarks in connection 
with Dr. W. E. Dreyfus's brief article contained on page 
1043 of the Medic.\l Record of June 25. While I regret 
that my name, or that of any other physician, should be 
linked together with any "special" prescription — that 
practice is always liable to tempt thoughtlessness and 
superficial routine — I admit that the doses published by 
the doctor are fairly correct. It will be noticed that a 
teaspoonful contains a grain of potassium chlorate and 
the double dose of the tincture of ferric chloride. When a 
dose is given everj- hour the amount taken in the course 
of a day amounts to about 16 or 18 grains of the salt. 
That is as it should be according to my teaching of the 
last forty-five years, in the case olE a child of from two to 
six years of age". The same rules w^ere given in the American 
Medical Times of i860, in the second volume of Gerhardt's 
"Handbuch" (1876) and in my "Treatise on Diphtheria" 
(1880). 

From the latter, which I happen to find on my shelves, 
I beg to quote what I could never sufficiently impress on 
colleagues or students: (Page 160) "The local effect cannot 
be obtained with occasional doses, but only by doses so 
frequently repeated that the remedy is in almost constant 
contact with the diseased surface. . . . It is better 
that the daily quantity of twenty grains should be given 
in fifty or sixty doses than in eight or ten ; that is, the 
solution should be weak, and a drachm or half a drachm 
of such a solution may be given every hour or everj- half 
hour, or every fifteen or twenty minutes, care being taken 
that no water is given soon after the remedy has been 
administered for obvious reasons." 

One of the main effects of the potassic chlorate is its 
preservative influence on the mucous membrane of the 
mouth, which should be kept as intact as possible to guard 
against the spreading of the membrane. From that point 
of view the recommendation to use the mixture in question 
as a gargle cannot be objected to. But (i) small children 
do not gargle, and (2) "gargles are not of much service" 
(in diphtheria) "for the simple reason that they do not 
come mto immediate contact with the affected parts, and 
reach at the utmost to the anterior pillars of the soft palate" 
(page 192). I cannot help being delighted with my 
knowledge of the fact that this simple observation, prob- 
ably not even original, and published by me first, forty- 
four years ago, has often been rediscovered and has given 
rise to numerous essays. 

I have reason to believe that the composition as found 
in many drugstores is not always equal to that which is 
published by Dr. Dreyfus. The proportions given by 
him are. as I said, fairly correct. His chemical expositions 
are very gratifying. The individual physician will make 
such changes as will suit his case or cases. Very prob- 
ably the next edition of the "Bellevue Hospital Formu- 
lary" will make appropriate alterations if the formula will 
ever be reprinted. I never knew it formed part of the 
formulary imtil lately. President Brannan was good 
enough to promise a revision at the proper time. 

A. J.\coBi. M.D. 

Bolton Landing. Lake George, N. Y.. June 16. 1904. 



The Blood in Malignant Disease. — Ernest Cunliffe. as 
the result of a year of fellowship work upon the blood in 
carcinoma and sarcoma, formulates the following con- 
clusions: (i) There is a constant decrease in the h:emo- 
globin and haemoglobin index. (2) The number of red 
cells is unaffected until the disease is advanced or the 
patient has suffered loss through hemorrhage. (3) Leu- 
cocytosis is the rule. It is caused especially by hemor- 
rhage, metastasis, ulceration, and septic infection. It 
may be absent, however, throughout. Its sudden occur- 
rence in such an instance indicates the probability of a 
metastasis. (4) The polymorphonuclear neutrophiles 
are increas*"' in number. This feature may be present 
without th otal number of leucocytes being raised, and 
in this relation points to the presence of malignancy. It 
is therefore a diagnostic sign of importance. — Medical 
Chronicle. 



July 2, 1904] 



MEDICAL RECORD. 



27 



prngrpsa nf Mpiiiral ^rintrr. 

The Boston Medical tiijj Siirgioal Journal, June ^3, 1904. 
A Case of Labor in an Epileptic. — Annie Lee Hamilton 
gives the history of this interesting case. The patient 
was a primipara, twenty-six years of age. She had been 
subject to epileptic attacks for twelve years. She had 
sometimes had as many as two or three attacks in a week. 
During her pregnancy they were less frequent up to the 
sixth or seventh month, then rather more frequent 
between the seventh and eighth months. Up to Decem- 
ber 8, four days previous to her entrance to the hospital, 
she had not had a convulsion for four weeks. On Decem- 
ber 8 she had three, and two or three on each ensuing day 
until the eleventh, when she had five before coming to the 
hospital. She was now about eight and one-half months 
pregnant. She seemed to be in pain, and at first she 
resisted examination. The patient had two convulsions, 
and it was decided to dilate manvially and deliver. There 
was no laceration. The patient soon apparently recov- 
ered from the ether but did not recover consciousness. 
The baby did very well for the first week but died within 
a few weeks of convulsions. The patient's condition for 
several days required very close watching. Finally, on 
December iS. she began to improve, and in talking, kept 
to the line of thought very well. On December 31 she 
was sent home, in very good condition. The treatment 
in the hospital was chiefly symptomatic. Elimination 
was carefully looked after and the nervous symptoms were 
treated by sodium bromide and hydrotherapy. Since her 
return home the convulsions have been decidedly less fre- 
quent. There seems to be very little in the literature in 
regard to this condition. 

Medical Ncu^s, June 25, 1004. 

The Tracheal Traction Test as an Aid in the Recognition of 
the Asthmatic Lung. — Albert Abrams concludes that; When 
the head is thrown forcibly backward, the normal reso- 
nance obtained by percussion over the manubrium and 
lungs contiguous thereto, becomes converted into a dull or 
iat sound. This nianoeuver the writer has called the 
tracheal traction test. The tracheal traction test is posi- 
tive in health and in all cardio-pulmonary affections, but 
it is negative in cases of idiopathic asthma. The recogni- 
tion of this test affords a valuable aid in the diagnosis of 
idiopathic asthma, and assists in its differentiation from 
symptomatic asthma and other spasmodic pulmonary 
affections which suggest an asthmatic genesis. The man- 
reuver specified as tracheal traction, evokes contraction of 
the bronchial muscle by stimulation of the pneumogastric 
nen.-e6. In asthma the tone of the bronchial muscle is so 
reduced, that it no longer responds to vagus stimulation 
brought about when the neck is forcibly extended on the 
sternum: hence, the tracheal traction test in idiopathic 
asthma is negative. 

Acute Thyroidism Following Curettage. — Brooks H. 
Wells reports a case of this nature. The patient, aged 
fifty-three, had passed the menopause at the usual time, 
but for the last six months had had repeated small bleed- 
ings from the uterus which was not enlarged and was 
freely movable. The patient for many years had had a 
slight enlargement of the right lobe of the thyroid, slight 
tremor, but no protrusion of the eyeballs. To exclude 
cancer of the fundus, a curettage of the uterus was per- 
formed. The scrapings showed only a moderate grade of 
endome>tritis. Six hours after the operation, the patient 
was flushed, tremulous, nervous and voluble, although her 
mind was clear. The pulse had risen to 130, and the tem- 
perature was 100.5° F. These symptoms increased in 
severity, excepting the temperature which fell. The thy- 
roid was enlarged, especiallj- on the right side, and pre- 
sented quite an apparent thrill. There was marked 
throbbing of the heart and the large arteries. Examina- 
tion of the urine revealed neither albumin nor casts. 
There were many colon bacilli, however, and a few piis- 
cells. These symptoms of extreme toxaemia continued to 
the end of the first week. On the t<-nth day the tempera- 
ture reached 104.8° with a pulse of 148. There was no 
leucocytosis. Death was expected at any time from the 
fifteenth to the twenty-fourth day. The heart-action was 
most rapid and weak when the temperature was lowest. 
Diarrhoea ceased to be troublesome on the twenty-first 
day. On the twenty-fourth day the patient began to 
improve, and finally reached a condition approximating 
that before the operation. 

Iodine and Mercury to Combat Local Infections. — Aug. 
Stabler describes a general method of treating local infec- 
tions which has given him the most gratifying residts in 
many cases of various kinds. The solution of iodine which 
he applies to mucovts membranes, is as follows : A men- 
stnjum is made of equal parts of glycerin and water. To 
this is added tincture of iodine one drachm to the ounce, with 



a little belladonna and carbolic acid as local sedatives. 
This solution is applied through a simple hand atomizer 
to throat and nose, or to the uterus, vagina, urethra, or 
skin, in any way that is indicated. In using the atomizer, 
the patient holds the tube between the teeth with lips 
closed in the same position as in smoking a pipe, and 
breathes through the nose. The spray will come through 
the nose when the bulb is worked. Calomel is given 
internally in moderate doses, frequently repeated, and so 
mercuric iodide is formed in the system. In rheumatism 
this treatment achieves brilliant results. If used early, 
suppuration of the tonsil and joint and heart affections 
rarely occurs. In acute articular, the writer applies an 
iodine plaster to the affected joint. He also pushes the 
mercury intemallj', and gives a little acetanilid and salol. 
Subcutaneous affections, such as boils, felons, etc., are 
treated with the happiest results in this same waj-. The 
writer usually combines ichthyol and tincture of iodine, of 
each one part, with six parts boroglyceride. This is 
applied on lint or absorbent cotton, which is covered with 
parchment paper and a bandage. 

New York Medical Journal, June 25, it;04. 

Albuminuric Retinitis. — L. Webster Fox notes that 
the retinitis of Bright 's disease occurs in about 30 per 
cent, of all cases of this malady, especially with the con- 
tracted kidne)'. It is nearly always bilateral, but may be 
tuiilateral. He describes the changes found in the acute and 
chronic forms respectively and refers to the accoinpany- 
ing blood changes. Vision is nearly alwaj^s impaired or 
lost according to the number, extent, and situation of the 
hemorrhages. Prognosis as regards life is very grave. 
The treatment of the general condition will afford the best 
possible chances for improving the ocvilar area. The 
importance of the question of albuminuric retinitis lies 
in the necessity of making an early diagnosis, and the 
ability to do this is to a large extent denied the general 
practitioner, unless he has been trained in the use of the 
ophthalmoscope, as the symptoms, headache, and loss of 
vision are common to a number of less serious affections, 
and in the absence of expert advice on the subject such a 
patient might go wandering about aimlessly until too late 
to employ any measures which would be of any benefit 
whatever. 

A Plea for a Truer Therapy — Real Treatment of the 
Sick. — Dr. W. C. Abbott refers to the fact that many 
physicians have lost faith in drugs and constantly pre- 
scribe empirically without a clear conception of what they 
wish to accomplish. In regard to dosage he notes that 
the effective dose depends on both the absorptive and 
eliminative powers of the patient. It must therefore 
constantly vary in both amount and frequency. There 
being absolutely no way by which we can determine a 
priori the amount of any "drug which will produce the 
effect desired in any given case, it is left for us to find that 
dose by giving to effect — either remedial or physiological 
— beyond which we should not go. The only avenue of 
escape from therapeutic nihilism lies along the road of 
medication by active principles in small doses given to 
effect. Not alone by deduction is this the only" rational 
therapy, but clinical experience with the active principles 
proves it absolutely. There can be no hesitation in 
adopting the active principles, if we admit the obvious fact 
that all medicinal action that a drug possesses is the 
result of the presence in that drug of one or more active 
principles. If of one, then does this active principle 
contain in itself a full expression of the therapeutics of the 
drug? If more than one active principle is present, then 
is it not better and more scientific, more exact, to study 
the action of each separately, than to give such empirically, 
hoping to get the desired results, which perhaps depend on 
the presence in excess of a certain alkaloid? 

American Medicine. June 25, 1904. 

Primary Typhoidal Cholecystitis, with Calculi. — Francis 
S. Stewart operated on the patient, whose case he reports. 
For three weeks before operation the woman, aged twen- 
tv-six, was intensely jaundiced. On admission to the 
hospital the temperature was 101° F., and the pulse 100. 
The blood coagulated in one minute. When the distended 
fundus of the gall-bladder was opened, there came out a 
small quantity of clear fluid and then a large quantity of 
sand and greenish-vellow pus. A stone about three-quar- 
ter inch in diameter was removed from the sacculation 
near the cystic duct. The pus from the gall-bladder gave 
a pure culture of bacillus typhosus. After this report was 
received, a test was made for the Widal reaction with pos- 
iti^-e results. 

The Larynx in Beginning Pulmonary Tuberculosis. — W. 
G. B. Harland declares that examination of the larynx in 
all cases of tuberculosis can give important information. 
This may be positive or negative. In either case it will 
be of use in making a prognosis, and may give valuable 



28 



MEDICAL RECORD. 



[July 2, 1904 



assistance in arriving at a diagnosis. Frequently, slight 
changes in the larynx are observed earh' in tuberculosis 
of the lungs. These changes may be congestive or anae- 
mic. The writer declares that in the usual run of cases 
of beginning tuberculosis of the lungs, an examination of 
the larynx may give the first clue to the presence of the 
lung infection. When the larynx is the chief seat of the 
disease the diagnosis and prognosis must be founded on 
the local appearances present. In all cases the lesions 
observed in the larynx, as is true of those found elsewhere, 
will be of most vakie in making a diagnosis and prognosis 
when taken in connection with a thorough careful study 
of the case as a whole. 

Three Points of Interest Concerning Smallpox and Vac- 
cination. — Bernard Ktihn reports three cases from which 
several conclusions may be easily deduced. The first 
patient, a girl of ten, although she had a physician's cer- 
tificate of successful vaccination four or h\e years before, 
developed smallpox. No scars could be fotmd on her 
arms. Several days later the girl's uncle developed the 
disease. He had been vaccinated several weeks before 
contracting the disease. It was doubtless a case of spuri- 
ous vaccination due to poor virus. No vesicle was formed. 
A baby sister of the first patient, about seventeen months 
old, was vaccinated by the writer eight times, separate 
tubes of virus being used, the virus being very potent. 
None of them took, neither did the child contract small- 
pox, although she had countless opportvmities for doing so. 
Tliis must have been a rare case of natural immunity to 
smallpox and vaccinia also. The manufacture of vaccine 
virus should be more carefully supervised by the govern- 
ment. And more care should be exercised in the issmng 
of_ vaccination certificates and in admitting children to 
sc'nool on the strength of them. 

The Lancet, June 18, 1904. 

On the Etiology of Scurvy. — M. Coplans gives an exten- 
sive review of his personal experience with scurvy in the 
Transvaal and Orange River Colonies during the Boer war. 
lie concludes that the disease is not due either to the pres- 
ence or absence of any particular kind of food from the 
dietarj' but rather to an infection for which the food may 
act as a vehicle under conditions of impure storage or 
impure preparation. In his experience the disease pre- 
vailed in inverse proportion to the personal standard of 
hygiene, and this would seem to indicate that its infectivity 
depended on the insanitary habits and possibly the 
unwholesome occupations of those who were stricken with 
it. 

Lymphatics of the Larynx and Malignant Disease. — P. 

d<> Santi discusses the anatomy of the laryngeal lymph 
channels and believes that these anatomical considerations 
have a direct bearing on the matters of choice of operation 
and prognosis. .-Xs regards the former the question turns 
on (i) the site of the origin of the disease and (2) the stage 
in which diagnosis is made. If an epithelioma of strictly 
intrinsic origin is seen and diagnosticated early while it is 
still limited, thyrotomy is amply sufficient to eradicate the 
disease. Jn the absence of obvious glandular involvement 
experience has shown that there is no need to perform a 
set operation to remove the group of glands liable to infec- 
tion. On the other hand in most advanced cases of intrin- 
sic cancer which necessitate removal of one-half of the 
larynx the corresponding glands ought to be removed 
whether they seem enlarged or not. 

The Treatment of Tabes Dorsalis and Its Prognosis. — ■ 
Maurice Faure notes that while certain cases of syphilitic 
tabe. improve rapidly under vigorous mercurial treatment 
it is certain (i) that no tabetic gets well solely on account 
of the quantity of iodide or of mercury whicli he absorbs, 
and (2) that aggravation of the disease is more frequent 
among tabetics who are put on an antisyphilitic treatment 
in increasing doses than among those who are not treated 
in this way. It is necessary to avoid attributing exclus- 
ively to the action of heroic remedies, such as mercury, the 
relaxations and the diminutions in the symptoms of dis- 
ease which are sometimes obser\-ed in the majority of cases 
of tabes, for such ameliorations are the rule, and it is incor- 
rect to say that locomotor ataxia must be a disease which 
is necessarily and invariably progressive. The disease is 
steadily progressive in a third of the cases. It is arrested, 
improved, or gets well in about a fourth of the cases and 
in the remainder it proceeds very slowly with periods of 
quiescence only affecting the life of the' patient seriously 
on occasions, and during the rest of his life offering him 
the possibility of living a life the activity of which doubt- 
less must be diminished, but which is by no means very 
uncomfortable. .\s regards treatment, the best results will 
follow from care of the bladder, keeping the bowels open, 
attending to nutrition, pro\-iding against insomnia, com- 
pelling open-air life, preventing overwork, mental or phys- 
ical, and by attending to the circulatory system. 



British Medical Journal, June 18, 1904. 

Appendicular Colic. — W Hesketh Evans describes one 
of his own cases in which, from time to time, appendicular 
colic was severe. There was no rise in temperature or 
alteration in pulse, but the pain became so severe that 
operation was performed. On cutting open the excised 
appendix, a dark-brown, semi-solid, foul-smelling sub- 
stance oozed out. In the interior were several small pock- 
ets containing a similar substance with fecal odor. Large 
doses of opium would have probably masked the only 
symptom, and the termination might then have been fatal. 

A Case of Leukanaemia. — F. Parkes Weber reports this 
case and sums up the main features as follows: Progres- 
sive wa.xy pallor and asthenia v.^ith maintenance of sub- 
cutaneous fat; changes in the red-blood corpuscles rather 
similar to, but not so extreme as, those met with in true 
pernicious anemia; absence of true leukaemic changes in 
the blood, but presence of slight myelocythsemia and pres- 
ence of the in\-erted proportion of lymphocytes to poly- 
morphonuclears, which is found in cases of lymphatic pseu- 
doleuka?mia ; no abnormal amount of pigment in the urine ; 
changes found after death in the haemopoietic tissues, simi- 
lar to those which occur in cases of "mixed-cell " leuksemia, 
or pseudoleuk;cmia; abnormally firm consistence and 
increase of connective tissue in the bone-marrow from the 
shaft of a long bone; absence of enlargement of the ordi- 
nary lymph glands, but great hyperplasia of the spleen 
(haemal gland) and prevertebral haemolymph glands: 
absence of any reaction in sections of the spleen, liver, 
and kidneys for free iron, such as is found in pernicious 
anaemia. Charcot-Leyden crystals were not noticed in 
the bone-marrow, etc., but were not specially looked for. 
In spite of the poikilocytosis, the writer believes the dis- 
ease in the present case to have been primary in the bone- 
marrow 

The Deterioration of Vision During School Life. — Ettie 
Saycr h.as made a careful stud«r of this subject. She has 
discovered that, at six years of age, 3 percent, of school 
children ha\-e seriously bad vision, and 8S per- cent, can 
see 6-6 with each eye. At eleven years of age, 11 per 
cent, have seriously bad vision, and only 58 per cent, see 
6-6 with each eye. The rest have slight defects. The 
writer declares that no child's eyes were intended by nature 
to undergo the strain of accommodation for lessons, for 
six or seven hours every day of their lives, between four and 
fourteen years of age. But if compulsory education enforces 
it it becomes the duty of the Board of Education annuallj-, 
to separate those 20,000 children or more, whose vision is 
so defective that they are unfit physically, to devise for 
them a specially modified curriculum, and to provide them 
with glasses if their parents are too poor or too ignorant, 
to do so. There is plenty of skilled manual work to be 
done by the class which is so poor that the public has to 
pay for their education, and they should be taught from 
their earliest infancy to regard this as their special lot in 
life. Not only the child with defecti\e vision suffers, but 
also future generations. All eyes should be tested imme- 
diately on the child beginning its education, as to \-isuaI 
acuity; as to rapidity of perception; as to color blindness. 
.\tno time during school life should type smaller than pica 
be used. While infants should be allowed to use only 
chalk on cardboard. Reading should be learned from the 
blackboard. There is no defect more Hkely to be trans- 
mitted from parent to child, than that of defective eye- 
sight. 

Deutsche medisinische Wochenschrift, June 9, 1904. 

Tuberculous Pericarditis. — Scagliosi reports an instance 
of this rare condition as occurring once in 1077 autopsies 
made at the University of Palermo. The patient was a 
woman of sixty who died as the result of a pyelonephritis. 
.'\t the autopsy a moderate amount of serous fluid was 
found in the pericardium, and the inner layer was ir- 
regularly covered with small nodules, which were later on 
determined to be tuberculous. The lesion was proved to be 
primary in the pericardium, and the author thinlcs that the 
patient's age was the .predisposing factor in determining 
this localization. It is well knowm that the blood-vessels of 
the heart in older persons are usually more or less diseased, 
and thus offer a point of lessened resistance. Careful 
histological examination of all the other organs and the 
lymphatic glands failed to reveal any traces of tuberculous 
processes. It seems rational to assume, therefore, that a 
primary tuberculous pericarditis may exist as a disease 
entity. 

Rupture of a Tuberculous Abseess into the Trachea. — 
Gaudiani directs attention to the possibility ot a destruc- 
tion of the walls of the air passages by the softening of 
masses of tuberculous cervical lymph-nodes. This may be 
followed by a sudden invasion of the trachea and the 
bronchi, leading to death by asphyxiation. .An instance of 
this comparatively rare condition is reported as having 



July 2, 1904] 



MEDICAL RECORD. 



29 



occurred in a child of three, who had just recovered from 
what was supposed to be an angina. A few days later, 
sudden dyspnoea came on, and although a tracheotomy 
was done it was iinpossible to save the child. Autopsy 
showed that the trachea down to the bifurcation was 
surrounded by a mass of glands. A perforation had taken 
place and the bronchi were filled with cheesy masses. 
This case also shows the difficulties attending the proper 
diagnosis. The only differential point which distinguishes 
this from laryngeal stenosis is the character of this voice, 
which is but slightly affected in the former condition. 
No other symptoms may have been present to point to the 
extensive character of the diseased processes in the glands. 

Treatment of Injuries to the Diaphragm. — Rona calls 
attention to the seriousness of this class of injuries, in 
which the proper surgical treatment is an urgent necessity. 
The patient, a boy of fifteen, presented a stab wound of the 
chest between the eighth and ninth ribs, through which a 
considerable portion of omentum protruded, pointing to 
an injury of both the pleura and the diaphragm. The 
transthoracic method of operation was employed, and 
after exposing the eighth rib under Schleich anssthesia, a 
portion about 15 cm. long was resected. This disclosed a 
slit in the diaphragm about 4 cm. long, through which 
the omentum protruded. The latter was cut way after 
ligature and the stump dropped back into the abdomen. 
The upper border of the womid in the diaphragm was then 
sutured to the parietal peritoneum and the skin wotmd 
closed with the exception of the lower angle, in which a 
few strips of gauze were introduced for drainage. The 
patient made an uninterrupted recovery. 

A New Property of the Tubercle Bacillus. — Piatkowski 
presents a preliminary communication dealing with the 
difTerentiation of the tubercle and the other acid-resisting 
bacilli. His method is based on the observation that the 
acid-resisting bacteria may be isolated from a mixture 
by diluting a small quantity of the latter with water or 
bouillon (10 c.c.) and then adding two to three drops of 
formalin. This is thoroughly shaken in a test-tube, and 
after half an hoiir a culture is made in a plain agar, or a 
glycerin-agar tube. Successive cultures are made from 
the same mixture at intervals of about fifteen minutes. 
In one or more of these tubes a pure culture of the bacillus 
vnll be found. It appears that the group of acid-resisting 
bacilli is less sensitive to the action of the diluted formalin 
solution than other varieties of bacteria. But even these 
are killed after prolonged exposure to the formalin, and so 
the difference is one of time only. The formalin solution 
has no effect whatever on the morphological character- 
istics of the acid-resisting bacilB and does not affect their 
staining properties. The author considers that this 
method can be more simplified, and is making further 
researches in this direction. 

Berliner klinische M'oehcnsehrift, June 9, 1904. 

Gonorrhceal Phlebitis. — Heller reports an instance of this 
rather rare complication of gonorrhoea, a search of the 
literature disclosing the fact that this is only the twentj'- 
sixth case on record. The patient presented neither 
varicose veins nor any other factor which could be con- 
sidered as an etiological factor. About fotir weeks after 
a gonorrhoea, which had apparently subsided, he developed 
a marked phlebitis of the lesser saphenous veins and the 
pampiniform plexus, which gradually disappeared under 
appropriate treatment. The affection seems to be foimd 
most often in young men between the ages of twenty and 
thirty, and tisually comes on during the first attack of 
gonorrhoea, during the subacute stage. An arthritis was 
present in most of the cases reported. A varicose condi- 
tion of the veins was noted in but one instance, so that this 
cannot be looked upon as a predisposing factor. The 
veins of the lower extremity are involved in the large 
majority of cases, particularly the saphenous vein. The 
principal symptoms are pain and localized oedema, and the 
average duration of the disease is about six weeks. The 
prognosis is usually good, although a few fatal cases have 
been reported. The author considers that the process 
may be due to the rupture of some hidden focus, most 
likely prostatic, and the entrance of the septic material 
into the venous circulation. Treatment is that of 
phlebitis elsewhere. 

Fatty Degeneration. — Rosenfeld thinks that this term 
should be limited to that condition in which an organ con- 
tains more fatty tissue than is normally present. This 
must be determined by chemical or microscopical methods. 
The latter, however, seems inadequate in most instances to 
afford any reliable quantitive estimate of the fat present in 
anv given organ. Of the chemical methods, that which is 
based on the extraction by alcohol or chloroform seems 
most efficient. The author attempted to ascertain by 
experiments in animals which organs are the most liable to 
undergo a fatty degeneration. These were given phos- 



phorus, phloridzin, chloroform, alcohol, and various other 
materials. The liver was apparently the most quickly 
affected. As regards the heart, chloroform and canthar- 
ides had no effect, alcohol and potassium bichromate 
caused an increase of about 2 per cent., phosphorus and 
phloridzin about 4 per cent., and extirpation of the pan- 
creas was followed by an increase of 6 per cent. It seems, 
therefore, that there is no connection between the two in 
cases in which a patient dies from poisoning by chloroform 
and a fatty heart is found at autopsy. In the kidney a 
marked decrease in the amoimt of fat present is produced 
by cantharides and chloroform, very little change follows 
the administration of either phosphorus or potassium 
bichromate or extirpation of the pancreas, but a rather 
marked increase in the amount of fat is produced by 
alcohol. Muscular tissue, as a general thing, afforded the 
surprising picture of a diminution of the fatty elements 
rather than an increase. The author concludes from his 
observations that in those organs where fatty degenera- 
tion is present the fat arrives there by a process of 
migration. 

M unchener medizinische Wochenschrijt, June 7, 1904. 

Treatment of Skin Diseases with the X-rays. — M tiller 
reports on the employment of this agent in pruritus, 
hyperidrosis. and chronic eczema. By the use of mode- 
rately soft or even very soft tubes he obtained excellent 
results, but does not consider it wise to apply the method 
indiscriminately in these diseases without having tried 
other procedures. A case of pruritus vuU-ae of long 
standing which had resisted other treatment was entirely 
cured after five exposures. In the case of profuse sweat- 
ing of the hands, the exposures were followed by an ex- 
foliation of the skin, and from the new dermal covering 
this excessive perspiration was absent. Another patient 
with this condition in the anal region was also favorably 
affected. The cases of chronic eczema were freed from 
the itching and the indurated skin after a few exposures. 

Value of Lumbar Puncture in Meningitis. — Wertheimer 
believes that Quincke's method of lumbar puncture 
affords the means of offering a better prognosis in many cases 
of meningitis in children, especially in those instances in 
which this disease follows a pneumonia or acute infectious 
process, and in which the meningitis may with considerable 
certainty be considered of the serous type and free from 
bacteria' He claims that the therapeutic value is also 
considerable and believes that partial evacuation of the 
cerebrospinal canal should not be delayed until the test 
puncture has shown the presence of a "high intracranial 
pressure. Rather it should be done as soon as the general 
symptoms, particularly the condition of the eyes, point to 
an increased cerebral pressure, and then the puncturing 
may be kept up imtil the pressure disappears. The 
author reports a case in wTiich a meningitis followed a 
pneumonia, in which 560 c.c. of fluid werere moved from 
the spinal canal at intervals of several days. The fluid 
was proved free from bacteria. The symptoms subsided 
and the child made a good recovery. 

French and Italian Journals. 

A Case of Total Hysterical Deafness. — Bouyer has had 
imder his care a case of total hysterical deafness which 
developed suddenly in consequence of a violent emotion. 
There is complete "suppression of perception both by the 
medium of air and bone. The deafness has several tmies 
been momentarily suspended imder the influence of certam 
therapeutic measures, which appeared to play especially 
a suggestive role — insuflilation and electric treatment. 
The patient was able to preserve for several moments a 
normal perception, but soon the somids became confused, 
and were lost in a distant murmur, which signalled the 
progressive rettim of the auditory nerve to numbness, 
and the development of intellectual torpor. — Gazette 
Hebdomadaire des Sciences Mcdicales. May 29, 1904 

Intestinal Occlusion by an Enormous Uterine Fibroma; 
Entire Relief of the Symptoms by Means of Right Lateral 
Decubitus. — Paul Gallois reports this case of a woman 
forty years of age, suffering from an enormous uterine 
fibroma. Constipation was persistent, the abdomen ^yas 
distended, and the patient suffered from fever. Vomitmg 
was also a troublesome symptom. The patient could not 
eat, and grew cachectic. The condition was growmg 
alarming. It occurred to the writer to advise the patient 
to lie on her right side. He reasoned that this position 
would disengage the sigmoid flexure, and besides, it would 
throw the weight of the tumor on to the distended in- 
testinal loops and increase their power of evacuation. 
Soon after the patient was able to lie on her right side 
gas escaped from the intestine, and fsces were quickly 
passed. — Le Bulletin Medical, May 28, 1904. 

Hysterical Polydipsia and Polyuria of Eleven Years' 
Duration. — Sollier has observed a case of polydipsia and 



3° 



MEDICA-L RECORD. 



[July 



1904 



polyuria in a young woman who drank from 12 to 17 
litres of water "daily with no complication of alcoholism. 
The polydipsia had" been cattsed by a sensation of burning 
in the cesophagus, the effect of an acute hysterical attack 
which developed at the age of seventeen years. The 
burning sensation was relieved by drinking cold water. 
The polyuria, resulting from the polydipsia, persisted for 
eleven consecutive years, and then ceased, when the 
hysterical troubles were relieved. The patient was treated 
in a sanatorium by measures generally einployed in 
hysteria — isolation, rest in bed, and mechanotherapy. 
Within three months, a complete cure resulted without the 
aid of any hypnotic suggestion of any kind. — La Presse 
Midicale. May 28, 1904. 

A Large Foreign Body in the Nasal Fossae .^Texier 
reports this unusual case of a man without morbid ante- 
cedents who was suffering with a suborbital fistula. There 
was a mucopurulent discharge from the nose. The fistula 
was thought to be due to a fall which had resulted in an 
abscess of the cheek. Two years before the patient's 
arm had been amputated as a result of injury by the ex- 
plosion of a firearm. On examining the fistula, it was 
found that a probe could be pushed inward and back- 
ward for 12 cm. Rhinoscopic examination showed the 
presence of a foreign body which had gone through the 
septum, penetrating both nasal fossae. It proved possible 
to seize the object through the fistula orifice and extract 
it. It was found to be a piece of iron about the size and 
length of the little finger. It had penetrated the nose at 
the time of the explosion, but the injury of the arm had 
been so severe that the accident to the nose had passed 
unnoticed. — La Bulletin Medical, May 18, 1904. 

Results of Some New Researches on the Etiology of 
Rabies. — A. Negri states that in the nervous system of 
animals affecteci with hydrophobia is found a micro- 
organism of the nature of a protozoon. It is found in the 
cells of the cerebrospinal axis. In dogs which have died 
of rabies furiosa after subdural injections of the virus, 
they are found in the encephalon, especially in the cornu 
ammonis. They are round,, oval, or angular, when of large 
size. Many are smaller and round. They vary in size 
from I to 20 /U in diameter. The smaller ones are homo- 
geneous, the large ones granular, irregular in shape, 
nucleated, with one or more nuclei. They may invade all 
the cells of the nervous system, the cells of Purkinj^, the 
cerebral cortex, pons, medulla, and Gasserian ganglion. 
In rabies paralvtica the distribution is different; when 
inoculated in the sciatic, the disease is ascending, and 
attacks the cells' of the spinal ganglia, and is not found in 
the brain. The author has found this organism in one case 
in man. They are soon destroyed by caustic alkali, but 
are not injured by acids. Drying, heat, putrefaction, 
glycerin, water, and physiological solutions do not affect 
their virulence. — Lo Sperimeiitale, April, 1904. 

Movable Kidney and Enteroptosis. — H. S^r^g^ calls 
attention to the frequent coincidence of enteroptosis with 
the movable kidney. The latter condition is, in the great 
majority of cases, to be considered as one of the phenomena 
in the general process of splanchnoptosis. Gastro- 
intestinal troubles in general, particularly those of infancy 
and adolescence, handing down a defective state of 
nutrition, are the origin of the process of ptosis in 54 per 
cent, of the cases. Pregnancy, alone, without other 
antecedent morbid cause, followed by serious dyspeptic 
troubles, appears to be the first cause in the proportion of 
32 to 100. Multiplicity of pregnancies does not seem to 
augment the trouble to any sensible degree. Periodic 
congestion is noted as a cause. Traumatism is a rare 
cause. The treatment of the movable kidney, the writer 
believes to be essentially medical. As to surgical treat- 
ment, it should never be attempted till medical treatment 
has failed. The writer calls attention to the importance 
of the Gl^nard supporter. Besides this, he advocates the 
use of daily laxatives, the meat regime, and the use of 
alkalines. His results have been most encouraging. He 
believes in the use of the supporter even in cases in which 
the abdomen is not prominent. — Journal dc Medecine de 
Bordeaux, May 29, 1904. 

Four Conservative Csesarean Sections and One Destruc- 
tive One for Osteomalacia. — T. Morisani publishes five 
cases of cajsarcan section done for pelvic deformities, 
three rachitic, two osteomalacic. The children were all 
saved. One mother died of sepsis. In one the uterus 
was removed, while in the others it was left. The author 
advocates making an incision in the median line of the 
fundus, from the highest portion, extending as far toward 
the symphysis as is necessary. The incision should avoid 
the location of the placenta as far as it can be ascertained, 
as this lessens the danger from hemorrhage. Hemorrhage 
depends less on the cutting of large vessels than on a lack 
of uterine contraction. In the median line of the uterus 
there are few large vessels to be cut. The extraction is 



also easier, and there is less danger of rupture of the 
uterus in a subsequent pregnancy because the scar is 
firmer. The higher up the incision, the stronger is the 
uterine muscle cut through. There is also less danger of 
ventral hernia, since the incision does not reach near the 
symphj'sis. — Archivio di Ostetrica e Ginecologia, March, 
190 |. 

Comparison of the Agglutination of Different Tuber- 
cle Bacilli, in Relation to the Origin of the Bacilli 
and of the Serimis. — M. S. Arloing and Paul Courmont 
conclude that: fi) Certain homogeneous cultures of 
tuberculosis are not agglutinable by tuberculous serums, 
even by serums obtained by inoculation of this same 
culture. The origin of the cultures does not seem to be 
the cause of the failure of agglutinability. They can- 
not serve for serum diagnosis. 2) The homogeneous 
cultures which are agglutinable, are so. whatever be their 
origin, in contrast to all the tuberculous agglutinating 
serums. The writers do not refer to the degree of ag- 
glutinating power. (3) Reciprocally, the experimental 
tuberculous serums, whatever may be the origin (human, 
bovine, or avian) of the infecting tuberculosis, are 
agglutinating for all the specimens of agglutinable tuber- 
culosis. (4) Practically, the cultures of human tuber- 
culosis are agglutinated by the serums of bovine tuber- 
culosis and the cultures of bovine tuberculosis bj' the 
serums of human tuberculosis. The method of serum- 
diagnosis is then applicable to all kinds of tuberculosis, 
of whatever origin, on the condition of having a culture 
that is very agglutinable. (6) The study of -agglutina- 
tion does not allow of establishing very sensible differences 
between tuberculoses of different origin, especially be- 
tween human and bovine tuberculosis. — Lyon Medical, 
April 24, 1904. 

The Pathological Anatomy of Acute Delirium. — U- 
Alessi publishes the account of a case of acute delirium, 
with pathological findings and some observations on the 
case. The patient, a man of thirty-five years, was of 
peaceful character, and had never indulged to excess in 
alcohol or tobacco. The onset of the disease was sudden, 
with acute mania of riches: he became loqviacious. ir- 
ritable and incoherent, unable to recognize his friends. 
This increased to excitement, motor irritability, insomnia, 
refusal of food, and a fever of 37° to 42°. This condition 
went on to extreme debility, coma, and death. A culture 
made from the blood showed the presence of pure cultures of 
pyogenes communis, which was also found in the brain. 
Examination of the cells of the brain showed marked 
degeneration of the cells, an acute parenchymatous 
degeneration of the fundamental nervous elements, i.e. 
an encephalitis. The author thinks that the title used for 
such affections should be based on the pathological con- 
ditions found, rather than on the cUnical symptoms. 
Hence such a case should be called an acute parenchyma- 
tous encephalitis, rather than one of acute delirium. The 
cause of such an encephalitis may be a variety of organisms, 
as the bacillus of Bianchi-Piccinino, of Fraenkel. a 
streptococcus infection, or one due to pyogenes com- 
munis. — La Riforma Medica. April 27, 1904. 

Rays and Emanations. — P. Schivardi compares the rays 
derived from the Crookes' tube and those of radium. He 
says that radium gives forth three sorts of rays: alpha, 
with slight power of penetration, arrested by aluminium; 
beta, with strong penetrating power, passing through lead; 
gamma, identical with the x-raj'. A radium salt produces 
heat andjlight. Radium gives out positive, negative and 
s:-rays, like the Crookes' tube, but spontaneously, and not 
as a result of outside stimulation. It seems to emit a sort 
of gas, as it were, which attaches itself to various bodies, 
and gives them radio-active powers; these are the emana- 
tions of radium. Another kind of rays come from the 
Crookes' tube called the n-rays, which are invisible, 
obscure, and yet traverse wood, metals, and the human 
body. They do not pass through lead or pure water. 
They do not act on the photographic plate, but they in- 
crease the luminosity of phosphoresent bodies, and make 
the light of a lamp more brilliant. They also increase the 
sensibility of the retina. These w-rays are a vibratory 
phenomenon of the ether, while the radium emanations are 
a liberation of a small amount of electricity, expelled from 
atoms of radio-active substances. A phosphorescent body 
is increased in brilliancy in the presence of muscular 
activity, in the neighborhood of the nerve trunks, or the 
central nervous system. There is a small instrument 
based on this principle, by which the course of the motor 
nerves can be followed out. This consists of a simple 
phosphorescent carbon disk. By means of it the topog- 
raphy of the central nervous system may be mapped out, 
as well as the psychomotor areas in the cerebral cortex, 
and the language centers. The human body also emits 
n-rays, increased in power by the functioning of the body. 
These emanations may serve to explain the phenomena of 



lulv 



1904] 



MEDICAL RECORD. 



31 



telepathy and thought transference. Griffiths found radio- 
activity in the petals of odoriferous plants, such as the 
geranium. If a test instrument be placed over the speech 
center in the cortex, speaking will cause it to become 
luminous, especially in the presence of a low voice, while 
when silence supervenes the instrument becomes dark. — 
Gazzetia Medica di Roma, May i, 1904. 

Annals of Surgery, May, 1904. 
Stricture of the CEsophagus Due to Typhoid Ulceration. — 

J. E. Thompson reports three personal cases and has found 
nine others on record, a r&um6 of which is given: Case r 
was somewhat relieved by dilatation measures, but tinally 
died from inability to swallow. A similar treatment pro- 
duced permanent relief in cases 2 and 3. As to the exact 
nature of oesophageal ulceration in typhoid, we have no 
definite information. Louis considered them as due not 
to typhoid infection but rather as a complication due to 
the extreme malnutrition of the tissues. It is very prob- 
able that the ulcers at the lower end of the giillet are due 
to peptic digestion of the oesophageal mucosa. The 
ulcers have been observed in many cases of exhausting and 
long-continued sicknesses. It is noteworthy that out of 
the twelve recorded cases, eleven occurred in males. 

Rhinophyma. — W. W. Keen describes one case of 
rhinophyma resulting from an acne rosacea. In operating 
he excised the central portion of the growth from the upper 
margin of the diseased area down to the tip of the nose by 
an elliptical incision, the long axis of which corresponded 
to the bridge of the nose. H then sutured the edges. The 
pressure of the finger in suturing the lobules of tissue 
squeezed out from the ducts of the sebaceous glands a num- 
ber of columns of sebaceous matter, commonly known as 
"worms. " On the alae of the nose, as it was impossible to 
obtain a suitable ellipse, he contented himself by simply 
shaving off all the hypertrophied tissue The hemorrhage 
was not severe; not a single vessel had to be ligated. A 
few clamps applied for a few minutes and the sutures 
checked the hemorrhage almost entirely, and a little 
adrenalin solution applied on the raw surface where he had 
shaved it completed the haemostasis. Between the dressing 
and skin a bit of gutta-percha tissue was placed, so as to 
prevent adhesion of the dressing to the wound, which 
would retard the cicatrization. Recovery was rapid and 
complete. 

Postoperative Pneumonia with Experiments upon Its 
Pathogeny. — The conclusions of W. L. Chapman are as 
follows: (i) Prophylaxis. Care in ether giving lessens 
shock and respiratory irritation, which reach their maxi- 
mum when an unnecessarily large amount of ether is given. 
(2) The disinfection of the mouth and oropharynx by 
peroxide before operation is a rational precaution. (3) 
Adecjuate air space is of even greater importance in 
surgical wards than in medical. (4) A careful ausculta- 
tion and percussion of the chest should precede every 
operation, and if there be signs of disease, operations of 
election should be postponed until the chest condition is 
more favorable. (5) A complete clinical record of all 
cases of postoperative pneumonia, together with a record 
of the previous state of the patient, is most desirable, and 
such records will in time greatly enrich our incomplete 
knowledge of the factors which predispose to the com- 
plication. (6) It is possible to demonstrate experi- 
mentally the lesions produced by suffocation and etheriza- 
tion, and the same philosophy which explains post- 
operative pneumonitis may be applied to that which occa- 
sionally follows poisoning by carbon monoxide and illumi- 
nating gas. 

Lymphatic Constitution; Care of the Lymphatics During 
and After Surgical Operations. — F. Gwyer reminds us that 
infection is most commonly carried through the lymphatics, 
but that ordinarily the only care we take is to cut cleanly 
and not tear the tissues. We should exercise the same 
care in closing all lymphatic vessels and spaces as we do in 
occluding the blood-vessels. In operating on diseased 
glands he advises dissection to the point of exit of the 
vessel, which he then ligates as he would an artery or a 
vein. An additional value in his experience has arisen 
from the fact that the arterial supply enters at about the 
same point as the emergence of the lymphatic, and there 
has been less hemorrhage than otherwise. Ligation also 
facilitated the work, in that the vessels, lying usually to- 
ward the bottom of the wound, dissection is more dififi- 
cult, and if bleeding occurs, it is more difficult to control; 
but if dissection is carried to that point and a ligature is 
thrown about the pedicle, as it were, much time is saved. 
In order to close up lymph spaces he rubs over the ex- 
posed area sterilized vaselin or iodoform-lanoline. In 
case of ordinary abscesses he incises, washes out the cavity, 
swabs it dry, and then fills it with one of the above prepara- 
tions. The same plan is followed in the after-treatment 
of infected cases The ointment should be a soluble one. 



Hence bismuth, zinc oxide, and similar preparations are in- 
admissible. 

Skin-grafting Infected Areas. — By "infected areas'' 
S. F. Wilcox refers to raw surfaces which niay or may not 
ha\-e been originally aseptic but which have become 
infected and from which pus exudes. To successfully 
skin-graft such areas we must first render them aseptic. 
The author thus describes his plan of doing this. The 
night before the operation the ulcerating and surround- 
ing area should be cleansed as thoroughly as possible 
with green soap and hydrogen peroxide to remove the 
dried crusts and debris from the granulations. In case of 
very foul varicose ulcers, more time maj- be taken, and a 
compress wet with 50 per cent, solution of peroxide may 
be applied for a few days until the exudate is removed. 
After cleansing, the raw surface is covered with a com- 
press saturated with a i per cent, solution of formalde- 
hyde (the or inary 40 per cent, pharmaceutical prep- 
aration being the unit), and this compress is allowed to 
remain in place until the patient is on the operating table. 
When the compress is removed, it will be found that the 
granulation layer is dry and dark red in color, having an 
appearance much like smoked beef. This layer is about 
a quarter of an inch in depth; it is friable, ani can easily 
be scraped off with a sharp spoon from the underlying 
tissue, which is whitish and bleeds very little. The re- 
moval of the granulation layer should be thorough, and 
what little oozing there is can be easily be stopped by the 
application of the Esmarch solid rubber band for a few 
minutes. The use of the rubber is a valuable step in the 
operation, as the smooth rubber makes equable compres- 
sion and does not stick to the tissues when removed, but 
leaves an ideal surface for skin-grafting. The remainder 
of the operation is the ordinary one for the application 
of Thiersch's grafts. The after-treatment is the same. 

Sialolithiasis. — According to O. T. Roberg, there are a 
few over two himdred cases of this condition on record. 
He describes one case occurring in a man of fifty-eight 
years who presented a condition leading to the diagnosis 
of calculus in Wharton's duct and probably in the sub- 
maxillary gland with suppuration of the latter and with 
suppurative cellulitis of the neck. An incision was made 
under local anjesthesia into the mass, and a small amount 
of thick, curdy pus escaped. One week later the swelling 
was considerally smaller and pus had ceased to discharge. 
The patient was then anesthetized. The nodule in the 
mouth was incised, and by means of a small curette a 
concretion the size of a split pea was removed. An in- 
cision about three inches long was then made extemalh", 
parallel with the lower border of the jaw, and one-half inch 
below it. By means of blunt dissection through a mass 
of dense scar tissue the submaxillary gland was exposed 
and removed. The wound was packed with iodoform 
gauze, and only partly closed. A second calculus was 
found lodged in the beginning of the duct. Five weeks 
after the operation the wound was completely closed. 
After the operation there was paresis of the angle of the 
mouth, from which the patient had completely recovered 
four months later. Concerning the relation of bacteria to 
the formation of salivary calculi, the author believes that 
they cause a precipitation of the calcium salts by in- 
creasing the alkalinity of the saliva and removing the 
carbon dioxide. This explanation, however, does not 
accftunt for the fact that calculi are found far more fre- 
quently in the submaxillary gland and duct than else- 
where. 

Haemoptysis. — In the treatment of hjemoptysis, Dr. W. 
von Bozoky does not approve of too much energy in this 
direction. The patient should be laid down with neck and 
chest freed from the pressure of clothing, and the upper 
portion of the body raised in order to facilitate expectora- 
tion. Then the patient should take deep breaths, which 
tend to restrain hemorrhage by inducing coagulation of 
blood and thrombus formation. Coughing should be 
checked, in order that the formation or development of a 
thrombus may be, as far as possible, promoted. Only a 
few slight coughs may be permitted, in order to get rid of 
the blood present in the upper air-passages. A morphine 
injection may be gfiven with the view of calming the pa- 
tient. The ice-bag may also have a favorable psychical 
influence. Ergot is not of much use; it tends to raise 
blood-pressure, and is not likely to be of avail in haemo- 
ptysis. He does not approve of injections of gentian, 
which do not seem to have a favorable influence and are 
also attended by the risk of tetanus. — Zeitschrift fur 
Tuberkulose und Heilstditenwesen. 



32 



MEDICAL RECORD. 



[July 2, 1904 



The Gazette Pocket Speller and Defi.ver. English 
and Medical. Second Edition. New York: The Ga- 
zette Publishing Co., 1904. 
This tiny volume of 216 pages is so compactly arranged 
that it can easily be slipped into any pocket. It is unusu- 
ally comprehensive for its size. The words in the English 
section are briefly defined, mainly by synonyms. In the 
revision of this little volume nearly 700 English and more 
than 300 medical words have been added without increas- 
ing the size or number of pages. It is an extremely con- 
venient little manual. 

Obstetrics for Nurses. By Joseph B. De Lee, M.D., 
Professor of Obstetrics, Northwestern University iledi- 
cal School; Obstetrician to Mercy, Wesley, Provident, 
Cook County, and Chicago Lying-in Hospitals; Lec- 
turer in the Nurses' Training Schools of same. Fully 
illustrated. Philadelphia, New York, London: W. B. 
Saunders & Company, 1904. 
Although this book is'intendcd by the author to be pri- 
marily for nurses, it is nevertheless, full of material valuable 
to the medical student, who frequently finds in his early 
years of obstetric practice the work of a nurse devolving 
upon him. Two main subjects are considered — obstetrics 
for nurses and the actual obstetric nursing. But the author 
has so skilfully combined them that the relations of one to 
the other are natural and helpful. This whole subject is 
one of such vital importance that a book of this kind, em- 
bodying as it does the experience of eight years of lectur- 
ing to the nurses of four different training schools, is most 
welcome to all those interested in obstetrics, whether nurses 
or physicians. The text is divided into three parts: 
Anatomy and Physiologv of the Reproductive System, 
Nursing During Labor and in the Puerperium, and The 
Pathology of Pregnancy, Labor, and the Puerperium. 
There is an appendix treating of Visiting Nursing in Obstet- 
ric Practice, Hospital vs. Home Nursing. The Obstetric 
Nurse and Dietary. An excellent glossarv and an index 
are appended. The illustrations, which are plentiful, are 
nearly all original, and were made expressly for this book. 
The author has taken the photographs from actual scenes, 
so that the details are true to life. We can warmly recom- 
mend this work. 

Maladies des Pays Chauds. Manuel dc Pathologic Exo- 
tique. Par Patrick Manson. Traduit de f Anglais 
par Maurice Guibaud, MMecin de la Marine, jean 
Brengues, M^dccin del'Arm^e Coloniale, et Augment^ de 
Notes et d'un Appendice par M. Guibaud. Avec 114 
illustrations et 2 planches en couleurs. Paris: C. 
Naud, 1904. 
The interest in tropical diseases has assumed such im- 
portance of recent years that a contribution to the subject 
like this comprehensive work now translated into the 
French language, is a most welcome addition to this 
branch of literature. In the introduction the author con- 
siders the etiology- of tropical diseases. The book is di- 
vided into seven sections. In the first, various fevers are 
considered — malaria, yellow fever, bubonic plague dengue, 
Mediterranean fever, tropical typhoid, tvpho-malaria, 
stmstroke, unclassified fevers, etc. The second section 
treats of beriberi, epidemic dropsv, and the sleeping sick- 
ness. Then follow the abdominal affections — cholera, 
dysentery, diarrhoea, liver abscess, infantile biliarj' cirrho- 
sis, etc. Leprosy, ulcerating granuloma of the genitals, 
and Oriental bubo are then discussed. Diseases due to 
animal parasites and associated maladies are accorded 
considerable space, and include such affections as Ivmphan- 
gitis. lymph scrotum, elephantiasis, bilharzia hsematobia, 
endemic hematuria, craw-craw, trichoccphalus dispar, 
ascarislumbricoidcs,ankylostomumduodenale,strongvlus, 
subiilis, taenia and nana', and bothriocephalus mansoni. 
The section on cutaneous diseases is divided into four 
parts, non-specific diseases, diseases due to bacteria, those 
due to vegetable parasites and those caused by animals. 
The last chapter deals with local maladies of an undeter- 
mmed nature. One hundred and fourteen illustrations 
are scattered throughout the text. There are, besides, 
two colored plates. 

A Manual op Hygiene and Sanitation. Bv Seneca D. 
Egbert, A.M., M.D., Professor of Hv.eieneand Dean of 
the Medico-Chirurgical College of Philadelphia; Mem- 
ber of the Academy of Natural Sciences of Philadelphia ; 
Mcrnber of the American Medical Association. Third 
edition, enlarged and thoroughlv revised. Illus- 
trated with 86 engravings. Philadelphia and New 
iork: Lea Brothers & Co.. 1904. 
The third edition of this valuable book will receive a warm 
welcome from the many classes to whom it appeals. The 
treatment of the subject is so scientific and systematic 
that the book fills a want not well met bv many other 
volumes on these topics. Since its appearance, five years 
ago, the text has increased bv more than one-third of its 



original vol'.ime. The atjthor has shown in the introduc- 
tory' chapters what practical hygiene and the employment 
of comparatively recent discoveries in this field are doing 
for the improvement of this country, the data being de- 
rived from the Reports of the United States Census of 1900. 
The writer calls attention to the fact that improvement of 
sanitary- conditions within ten years has resulted in the 
lowering of the death rate for almost twenty-nine mil- 
lions of people, for consumption, 24 per cent. ; for typhoid 
fever, 27 per cent.; for diphtheria, 50 per cent.; and for 
malaria 54 per cent. The reduction of the general death 
rate for the same number of ])eople means a saving of 
almost fifty-two thousand lives, as well as the prevention 
of an incalculable amount of sickness. The volume deals 
with personal as well as public health, and is an invaluable 
addition to the library, not only of the physician but also 
of the layman. 

The Joh.vs Hopkins Hospital Reports. Volume XI. 

Baltimore: The Johns Hopkins Press, 1903. 
This volume of the reports contains three monographs: 
(i) Pneumothorax: A Historical, Clinical, and Experi- 
mental Study, by Charles P. Emerson. A.B.. M.D. (2) 
Clinical Observations on Blood-pressure, by Henry Wire- 
man Cook, M.D., and John Bradford Briggs, M.D. (3) 
The Value of Tuberculin in Surgical Diagnosis, by Martin 
B. Tinker, M.D. The writer of "Pneumothorax" pre- 
sents an exhaustive study of this subject. The first chap- 
ter gives a historv' of numerous cases reported by many 
different \\-ritcrs, going back to the earlier times. In later 
chapters the history, etiology, and pathology, with the 
clinical histories of cases, the mechanics of pneumothorax, 
the symptoms, course, prognosis, diagnosis, and treatn'ent 
of the disease are discussed. The authors of "Clinical 
Observations on Blood-pressure." give the history of the 
principal methods of clinical sphygmomanomctry ; blood- 
pressure observations in svirgical cases, in obstetrical cases, 
and in medical conditions. Thej- finally treat of the com- 
parative value of general stimulant measures. In the last 
paper, the value, dose, harmful use, injection, preparation 
and reliability of tuberculin in surgical diagnosis are dis- 
cussed. 

The Practical Care of the Baby. By Theron Wendell 
Kilmer, M.D,, .Associate Professor of Diseases of Chil- 
dren in the New York School of Clinical Medicine ; .As- 
sistant Physician to the Out-patient Department of the 
Babies' Hospital, New York; Attending Physician to 
the Children's Department of the West Side German 
Dispensary-, New York. With sixty-eight illustrations. 
Philadelphia: F. A. Davis Company, 1903. 
The author has presented his subject in a clear, concise, 
and interesting manner. He has gone into the explana- 
tion of details in a most painstaking fashion. The text is 
made very clear by numerous illustrations. The proper 
development, clothing, and feeding of the infant are all 
discussed. Then follow chapters on the diseases incident 
to babyhood. Finally, there are sections treating of the 
Nursery, the Wetnurse, Bad Habits, and Food Recipes. 
The text is so plain that the book cannot help but be of 
great ^-alue to mothers and nurses as well as to ohysicians. 
A Manual of Clinical Diagnosis by Means of Micro- 
scopical and Chemical Methods. By Chas. E. 
SiMO.v. M.D. Fifth Edition, revised and enlarged. 
New York and Philadelphia: Lea Brothers & Co., 1904. 
Since its first appearance in 1896 this work has come to be 
regarded as one of the standards in this country in its 
particular field. The great strides made in this subject 
during recent years have necessitated frequent additions 
to the book in its successive editions, and the present one. 
the fifth, has attained the dimensions of a large octavo 
of almost 700 pages, with numerous illustrations. The 
purpose of the book is well stated in the author's preface, 
where it is said that exact methods of diagnosis necessarily 
underlie successful therapeusis. and should therefore be 
part of the equipment of every physician, Dr. Simon 
has at tempted to simplify the physician's work and to in- 
crease its efficiency by enabling him to eliminate doubt 
from his diagnosis. Besides a careful revision, this edition 
embodies much new matter which has appeared during the 
last few years. The section on the blood has been entirely 
rewritten and has been enlarged by sixty pages, especial 
pains having been taken with the chapter on technique. 
A section dealing with the nature of anihn dyes and the 
principles of staining has been introduced. For con- 
venience of reference, the subject of leucocytosis has been 
arranged in such a manner that hypcrleucocytosis and 
hypoleucocytosis are separately considered in connection 
with the different varieties of leucocytes. .\ new section 
deals with the cryoscopic examination of the blood. The 
chapters on the parasitology and bacteriology of the 
blood have been enlarged, with separate sections on 
paratyphoid fever, gonococcus septicjemia. bubonic plague, 
trypanosomiasis, and spotted fever. Many other additions 
an'd changes have also been made in other sections. 



July 2, 1904] 



MEDICAL RECORD. 



3j 



^nmtij SlfiinrtB, 



NEW YORK ACADEMY OF MEDICINE. 
Stated Meeting, Held May 19, 1904. 
Dr. Virgil P. Gibney, in the Chair. 
The Distinctive Character of the Temperature Curve 
of Measles, and of Scarlet Fever — the Treatment of Hyper- 
pyrexia in These Diseases. — Dr. H. W . Berg read this 
paper (see page i). 

Dr. Henry Koplik said that the temperature curve 
during the enanthemata could not be considered 
exact as yet, because there had not been enough cases 
under observation to warrant any conclusion. Dur- 
ing the enanthemata there would be apparently a slight 
rise of temperature, which might fall to normal, rise agafn 
and, in two or three days, ■would rise further with 
the appearance of the eruption. As to there being any- 
thing characteristic about the prodromal stage he hesi- 
tated to state; there was in all probabilit)- the tempera- 
ture curve of an infection, same as would appear in an 
attack of tonsillitis or other infections. Even before the 
enanthemata there might be a slight rise, the child not 
being apparently well, running a temperature of one- 
half or one degree. There it was difficult to say when 
the temperature curve began or when it ended. With 
reference to the critical drop in measles he said that Dr. 
Berg was correct in the chart drawings, but there were un- 
complicated cases which did not show this critical drop ; 
in other words, all cases did not conform to this critical 
dropcurve, because there were many cases recorded without 
any complications, so far as one could tell after the most 
careful and painstaking examinations, in which the tem- 
perature dropped by lysis. He could not, therefore, 
support Dr. Berg's assumption that uncomplicated cases 
of measles dropped by crisis. With regard to the state- 
ment of Dr. Berg that he had never seen a case of measles 
without temperature being present, he referred to a baby 
that was under observation for six days, and he did not 
know what the matter was. The baby was brought into 
the hospital with a slight bronchitis, and for a day it 
was watched carefuU}-. The temperature was normal, 
being 99 . 4° by rectum. Soon the child broke out with 
an eruption, there was a conjunctivitis, the spots were 
well shown in the mouth, and the case proved to be 
one of well-developed measles. The baby was transferred 
to Riverside Hospital. Here was a well-marked case of 
measles without scarcely any pyrexia. 

In regard to the scarlet fever temperature curve, he 
agreed with Dr. Berg that it acted as depicted by him in 
normal cases, but he said he had seen cases with tempera- 
tures of 103°, 104°, etc., which failed to drop, and when 
there were no complications. In these cases there was 
general enlargement of the lymphatic glands and a severe 
dermatitis. He remembered distinctly just such a case 
in which he was asked to point out the complication 
which kept up the fever; he looked for it everywhere 
but failed to find one. He thought it might be explained 
by the fact that the desquamation was so marked, 
and the glandular enlargement and toxaemia so marked 
that it kept the temperature running a week or two. 
He would endorse Dr. Berg so far as he had gone. 
There was nothing so typical as a scarlet fever 
normal curve, and nothing so varied as measles 
when the eruption was at its height to predict whether 
it would show a critical drop or not. There was another 
class of cases that had not been referred to in which there 
was no typical temperature curve at all, i.e. the malig- 
nant cases with temperatures remaining at 105°, 106°. 
To build a therapy upon the temperature curve he 
thought would be rather risky, for each case should be 
studied by itself. If left alone he believed the normal 
cases of measles would get well: at the same time, if the 
temperature remained up he did not hesitate to sponge 
them and adopt mild measures. He did not recommend 
cold sponging, but luke-warm water, as a rule. The 



more he saw of scarlet fever the le.ss he felt that 
he knew of its treatment, and he believed that each case 
should be studied by itself. Lately he had seen a child, 
six years old, who was very ill with scarlet fever, and 
what helped this child more than anything else was 
placing him in the cold pack and then adding cold water; 
here no sponging was used. On the other hand, in pri- 
vate practice, he treated his cases of scarlet fever with 
sponging; some children bear cold sponging well with good 
reaction, and others bear warm sponging well. Again 
some children may go to pieces in a bath at 80°, but if 
the water was raised to 100° it would revive them. 

Dr. Alexa.nder Lambert said that his experience 
coincided in the main with Dr. Berg's. Measles was as- 
sociated with ^ distinct crisis, but the typical absolute 
crisis, as depicted on the charts, was the exception rather 
than the rule. When complications appeared, as a sud- 
den attack of bronchitis, a temperature of 105° may be 
reached within thirty-six hours. He referred to one girl 
who had the typical rash, general adenitis, slight throat 
symptoms, etc. It was a very brilliant rash, and the 
case went on to complete desquamation at the end of 
six weeks, and at no time was the temperature above 
99°. In another case there was the red and congested 
throat, the rash, adenitis, and a marked general desqua- 
mation and no temperature. He agreed with Dr. Kop- 
lik that in cases of scarlet fever, with very brilliant erup- 
tions, in uncomplicated cases, the temperatures may 
run along for two or three weeks before coming to the 
normal. 

Dr. Wm. p. Northrup said that measles, scarlet fever, 
and smallpox had exact charts, and related an instance 
in which he predicted what the chart would be in a child 
who contracted the disease from her sister who was suf- 
fering from scarlet fever. The thennometer should not 
be studied so much but the child's condition. He ad- 
vocated the use of water inside and out, and said that 
the old adage, "keep the feet warm and the head cool," 
was a good one to follow. 

Dr. Berg closed the discussion, and said that a great 
deal hinged upon the question of complications, and 
sometimes even the most astute clinician would overlook 
a complication. The question of irregular temperature 
curve at once raised the question as to the existence of 
complications. He was interested in what Dr. Koplik 
had stated regarding those cases which presented no 
temperatures in measles. He was very skeptical regard- 
ing such statements, because every case that he had 
noted showed a temperature rise of from one-half to one 
degree above the normal. With re.gard to scarlet-fever cases 
he had seen children playing and seemingly enjoying life 
when they had temperatures of 103.5°. He was skeptical re- 
garding any acute eruptive disease going through its course 
without temperature. In reference to the malignant 
temperature curve of measles and scarlet fever he believed 
the word malignant brought at once before one's eyes the 
most toxic cases, and the high temperatures depended upon 
the septic manifestations, and these cases he did not 
include as being uncomplicated. By studying these 
curves he said he was able to look for complications 
which otherwise would have escaped his observation. 

In regard to balneotherapy it was his custom to place 
the patient in a luke-warm bath at 80°, and raise the tem- 
perature about 10 degrees, thereby practically giving a 
warm bath after a cold one; by so doing he got rid of 
toxins, and the temperature would be lowered e\'en fur- 
ther than if a bath at 60" had been given. He had seen 
temperature of 105° drop to 99 . 5° after one of these baths 
and stay there for nine or ten hours. 

A Few Words Concerning Radium. — Dr. H. G. Piffard 
read this paper (see page 999. Vol. 65). 

Dr. Robert Abbe said that he wished to express his 
opinion regarding this extraordinary agent, for he be- 
lieved that there certainly was something in it ; it was a 
\-erj' subtle agent, and was similar to the a:-ray, the ultra- 



34 



MEDICAL RECORD. 



[July 2. 1904 



violet, the Piffard, and Finsen rays. In its efficiency 
it lay between the j;-ray and the Finsen light. Dr. 
Abbe then reported certain experiments that he had 
made showing the retarding effects of the radium upon 
the growth of seeds; the results were unquestionable. 
If twenty seeds were taken out that had been radiumized 
four days, and twenty more that had been subjected to 
its influence for two days, and twenty more that had not 
been radiumized, if these seeds were planted for ten days 
it would be shoisTi that the seeds unradiumized would 
have grown seven inches, those that had been subjected 
to its influence for two days woxUd have grown four 
inches, and those radiumized four days would have growTi 
only two inches. The retarding influence upon these 
seeds as a result of the influence of radium was unques- 
tionable. The same retarding effect was noted when 
the meal-worm was subjected to the influence of radium. 
Thousands of experiments had been made to show this 
retarding influence in both the vegetable and animal 
kingdom. Now if radium be laid upon the skin for a few 
hours it will produce a welt-like urticaria; the next day 
it will appear like a bum, and continue its effect, pro- 
ducing a dry necrosis, scaling off and leaving a scar with 
infiltration. A condition of necrosis and destruction 
of the tissue cells are produced. Under the microscope 
there will be found a leucocytosis, a thrombosis of the 
small blood-vessels, the nerves will be infiltrated, the 
leucocytes will infiltrate the tissues, all this excitation 
being produced by radium. Dr. Abbe had experimented 
upon himself and upon others. He found a suitable 
case for experimentation in the mammary gland which 
he was to amputate. There were two or three outlying 
nodes in the skin, and he allowed the radium on the skin 
for six hours on one place, then on another, etc., doing 
this for six days, when he had pathological lesions run- 
ning over a period of six days. He then took a piece of 
radium and plunged it into the mammary growth, leav- 
ing it there for twenty- four hours, and then amputated 
the breast. The pathologist did the rest, and reported 
the following facts: For a distance of one-quarter of an 
inch there was a marked effect of the radium upon the 
tissues. The nest-cells had begim to be disorganized, 
and the superficial tissues of the skin necrosed. There 
was a vascular leucocyte infiltration which was very 
marked for one-quarter of an inch beneath in the mam- 
mary tissue, and at right angles to the line of section; 
there was a destructive necrosis of these nest-cells. The 
pathologist said he wanted tissue showing the influence 
of the radium for a longer period of time. He had an- 
other patient with cancer, and by the application of 
radium nineteen times in a period of three months he 
reduced its size one-third, and then cut out one of these 
cancerous nodules and gave it to the pathologist. Micro- 
scopically there was shown a fibrous infiltration and a 
reduction of the cancer cells, and the nest-cells were 
present, but much smaller in number. It wai interesting 
to note that one could produce practically the same effect 
with a weak radium with longer applications, as with a 
strong radium with short applications. Dr. Abbe re- 
ported the case of a young man with a giant-celled sar- 
coma of the lower jaw. Six months ago the gums be- 
came swollen around the left lower canine tooth, which 
became loose. Four months ago he sought advice at 
St. Luke's Hospital. A soft spongy dark tumor occupied 
the lower jaw from the middle portion toward the left, 
and bulged inward under the tongue and outward under 
the skin. It was so soft that it seemed to fluctuate. It 
seemed to rise between the teeth. Three teeth were so 
loose that they could be lifted from the sockets. A 
radical operation was impossible without great deformity, 
and with a surety that the growth would recur; there- 
fore he decided to trj' the influence of radium upon it, 
and this was applied over the growth within the teeth 
for one-half to one hour daily, a lead shield protecting 
the tongue. He next attacked the outer portion of the 



tumor by laying the tube between the lip and the tumor ; 
this so blistered the mucous membrane that he decided 
to penetrate the tumor; he penetrated the tumor in its 
\-arious parts, leaving the radium imbedded for two or 
three hours at a time. The growth was not onh- arrested, 
but there was an appreciable shrinkage in its bulk of 
about one-third its size. The boy to-day was in apparent 
perfect health. One week ago he took a trocar and re- 
moved a cj'linder of tissue from the tumor, and examined 
it microscopically, and it still showed that it was a giant- 
celled sarcoma, but merely a shell. Dr. Abbe had the 
influence of the radium upon the seeds, and the meal- 
worms in his mind all the time, and he believed that he 
had greatly retarded the grov^h. This was a vast prob- 
lem; he believed that, although the cells develop they 
can be held in check by radium, and he said what a tre- 
mendous contrast was presented in this patient \vith 
what would have happened if the growth had been un- 
radiumized. Lupus and other conditions can be cured 
by radium, and those using this agent were having suc- 
cesses in various other conditions. A wart was a typical 
hypertrophy of one of the layers of the skin, and prac- 
tically a tumor. He had a patient with warts upon both 
hands; on one hand he tried radium, and on the other 
monochloracetic acid ; the warts disappeared from the 
hands at the same time. Radium had an extraordinary 
effect in producing a retrograde metamorphosis. 



AMERICAN MEDICAL ASSOCIATIOX. 

Fifty-fifth Annual Meeting, Held in Atlantic City, A^ J., 

June 7, 8, 9, and 10, 1904. 

(Special Report to the Medical Record.) 

(Continued from page 1065. Vol. 65.) 

SECTION- ON OBSTETRICS AXD DISEASES OF WOMEN. 

Third Day — Thursday, June 2, 1904. 
The Surgical Treatment of Bilocular Uterus and Bifid 
Vagina. — Dr. H. W, Lo.vgyear of Detroit reteiTed to the 
meagre literature on this subject, and called attention to 
the fact that as the malformation was easy of correction, 
it should be operated upon as soon as discoN"ered, so as 
to avoid the accidents of pregnancy and parturition which 
are liable to attend this anomaly of development. Before 
operating care was necessary in making a differential 
diagnosis between uterus duplex and uterus bicomis. 
The treatment recommended consisted in dividing the 
septtim which separated the two uteri and vagina, and 
creating one cavity. The septum was grasped between 
clamps and cut ^\^th scissors, after which the Pacquelin 
cautery was applied to the cut edges, and the cavity 
packed with gauze. In the two cases which he reported, 
dysmenorrhoea was a marked symptom, but was relieved 
after operation, although in one of the cases an oophor- 
ectomy had to be done subsequently. 

Dr. Dunning of Indianapolis stated that he had seen 
two cases of bilocular utenis and vagina. During labor 
the septa were torn through. One was thin and offered 
little obstacle to the progress of the presenting part; the 
other was somewhat thicker. There was but light hemor- 
rhage. Both cases did well, and he doubted whether an 
operation was necessary, as a general thing. 

Dr. Johnson of Washington had seen a case in which, if 
operation had been done, much annoyance could have 
been avoided. The woman had been curetted for an 
apparent miscarriage and five months later was delivered 
of another foetus. The condition was then found to be a 
double uterus with a pregnancy in each. 

Dr. Carstens of Detroit reported two cases with septum 
which he divided, and although previously there had been 
miscarriages, full term pregnancy resulted. To prevent 
adhesions, he recommended the application of carbolic 
acid to the interior of the uterus after operation. 

A Plea for More Thorough Examination of Doubtful 
Specimens of Ectopic Pregnancy.— Dr. J . W. Bo\' e e of Wash- 
ington stated that many cases of ovarian and tubal hemor- 



July 2, 1904] 



MEDICAL RECORD, 



35 



rhage have a symptomatology precisely similar to dis- 
turbed tubal or tuboovarian pregnancy, particularly 
ttibal abortion. Specimens from such cases usually do 
not receive precise examination and are considered as 
pregnancy. For the sake of more reliable statistics, he 
thought that more careful histological examinations should 
be made. He reported ten cases in which the history indi- 
cated tubal pregnancy, but this diagnosis was not con- 
firmed by microscopical examination. In two, malignant 
ovarian tumors were found. 

Some Cases of Ectopic Gestation with Atypical Symp- 
toms. — Dr. W. B. DoRSETT of St. Louis called attention 
to the fact that many cases were occasionally found which 
did not present characteristic symptoms. Thus a right- 
sided tubal pregnancy might be mistaken for appendical 
inflammation. He had operated on forty-one cases with 
a mortality of six, and in some of these no diagnosis had 
been made, but other indications were present calling for 
surgical interference. He believed that the general con- 
dition of the patient should be made the gviide for sur- 
gical intervention and not alone the history of the case. 

Dr. C.'iRSTENS of Detroit said that he had a case of sup- 
posed appendicitis, without fever or increased pulse rate, 
which turned out to have been a right-sided ectopic. He 
claimed that it was right to operate first and decide the 
pathology afterward. 

Dr. M.\ssEY of Philadelphia entered a plea for more 
conservative measures in dealing with ectopic gestation, 
as in many cases nature had already begun the process of 
obsorbing the mass when operation was undertaken. He 
advocated the destruction of the foetus by the electric 
current, where practicable, as an aid to this process. 

Dr. GoLDsoHN of Chicago thought that the only diffi- 
culty lay in diagnosing the cases before rupture. In some 
cases microscopical evidence of the existence of a preg- 
nancy covtld only be found in the cavity in the center of 
the blood-clot. He considered that the idea of the 
digestive function of the peritoneum was far-fetched. 

Dr. HuMiSTON of Cleveland said that after rupture he 
did not wait for subsidence of shock before undertaking 
operation, but after injecting saline solution under the 
breasts, he proceeded to carry it out immediately. 

Dr. Dudley of New York considered that it was not 
necessary to remove the entire tube for non-septic con- 
ditions. After the foetus was turned out, the ovary and 
tube could be dropped back, all occlusions, etc., having 
been corrected. 

The Influence of Ovarian Implantation on Menstruation 
in Women. — Dr. A. P. Dudley of New York presented the 
following points for discussion: (i) Is the operation justi- 
fiable as a surgical procedure? (2) Is it worth the effort 
from a physiological standpoint? (3) Will the transplanted 
eventually resemble the fibroid in its action? (4) Is it 
possible that pregnancy may ultimately take place? (5) 
and provided it does, what is the prospect for normal 
delivery? Thus far he had done this operation in seven 
cases, all of which subsequently menstruated but at irreg- 
ular intervals, and no physiological changes or nervous 
manifestations resulted. One of his last cases he reported 
in full. The patient had had both tubes and one ovary 
removed, and for the relief of her symptoms, hysterectomy 
had been advised, but to which she would not consent. 
Operation was undertaken and the ovary freed from its 
adhesions, but left attached by the ovarian ligament, was 
implanted directly in the uterine cavity in a space pre- 
viously gauged out in the muscular substance. Primary 
union resulted and the woman menstruated three months 
after the operation, and then, at intervals, every three 
months. Eighteen months later she developed a severe 
menorrhagia, and hysterectomy had finally to be done 
three years after the first operation. Examination showed 
that the ovarian and uterine tissues had become merged, 
with Graafian follicles present. He was at a loss to ac- 
count for the hemorrhages. The specimens obtained 
from this case were presented at the meeting. The reader 



doubted the extended applicability of the method, but 
believed that it might be advantageously employed in 
isolated cases. 

A Plea for Conservative Operations on the Ovaries, 
from a Neurotic Standpoint, with a Report of Cases. — Dr. 

J. W. CoKENOWER of Des Moines read this paper, in 
which he called attention to the necessity of making 
a better diagnosis in those cases in which the symptoms 
presented were ascribed to ovarian disorders. In many 
instances it was questionable whether the trouble was 
really due to the ovary. It was much more likely to 
be an intoxication traceable to the intestinal canal, of 
which the pelvic disease was the result, rather than the 
cause. Neurotic cases were rare in which the symptoms 
were wholly dependent on the sexual organs. It was 
important to recognize when to conclude medical treat- 
ment and institute surgical measures. The consensus 
of opinion of many observers rather than the statistical 
reports of a few, should be given preference. Negative 
results for consen'ative ovarian operations for the relief 
of neurotic conditions were common, and between the 
two extreme views as to the advisability of operating, 
an intermediate view was the best. He reported four 
cases in which single or double oophorectomy and hyster- 
ectomy had been done, with disappointing results. He 
thought that in many cases we operated when we should 
not have done so. 

Dr. Morris of New York opened the discussion on 
Dr. Dudley's paper. He discussed the advantages of 
the procedure and the respective value of homoplastic 
and heteroplastic transplantation. He had madenumer- 
ous experiments on rabbits, and the latter method was 
imsuccessful. He thought that it was well to save the 
ovary in a case of pyosalpinx, and he foimd that the 
organs could be kept in hot saline solution for several 
hours without injury, before being transplanted and 
while the remaining operative procedures were being 
completed. In discussing Dr. Cokenower's paper, he 
called attention to the fact that it was essential to care- 
fully differentiate fundamental psychoses from neuroses. 

Dr. GoLDSPOHN of Chicago opened the discussion of 
Dr. Cokenower's paper. He thought the question might 
be solved by distinguishing between psychical and actual 
pain. Every other part of the body should be examined 
before the pelvis. He had also invariably found that 
pelvic lesions were aggravated by the erect posture or 
anything else that favored congestion. 

Dr. HuMiSTON of Cleveland found that frequently 
the pelvic organs were normal and other organs accounted 
for the neuroses. In discussing operative measures, he 
stated that he onlj' attained good results from the com- 
plete operations. 

Dr. Bacon of Chicago thought that the site of implantation 
was not favorable, as the implanted ovary might be 
washed away by the uterine discharges. He believed 
that the chief object was to secure the advantages of 
internal ovarian secretion , rather than the possibilities of 
pregnancy. 

Dr. Massey of Philadelphia considered that in many 
cases it was necessary to remove the inflammation rather 
than the organ itself, and in this connection he believed 
that kataphoresis with the mercuric ions valuable. 

Dr. Carstens of Detroit thought that occasionally in 
young women a favorable case for the Dudley operation 
might be found, but that in older women it was best to 
remove the ovaries if the symptoms were bad. 

Dr. Craig of Boston had observed that the normal 
ovary became scarred during middle life from cicatrization 
of the continually rupturing Graafian follicles, and that 
many so-called cystic ovaries, without clinical symptoms, 
contained merely enlarged Graafian follicles. As it was 
an essential thing to keep up the internal ovarian secretion, 
he believed thatimder the proper circumstances, Dudley's 
operation was favorable. 

Dr. Chandler of Philadelphia thought that Dudley's 



I 



36 



MEDICAL RECORD. 



[Tuly 



i(>04 



operation presented many advantages and but few objec- 
tions. Among the latter were the remote possibility 
of sepsis, the death of the ovarj-. the production of mahg- 
nancy, and the action on the fcetus. The main advantage 
he considered to be the postponement of the meno- 
pause. 

A Series of Mistaken Gynecological Diagnosis. — Dr. 
T. S. CuLLEN of Baltimore reported the following in- 
teresting cases: (i) Was diagnosed as a large multi- 
locular ovarian cyst, which at operation was found to be 
a pedunculated fibroid, partially parasitic The omentum 
was markedly atrophied and ascites was present. The 
latter is extremely rare with fibroid conditions. (2) Here 
the uterus was enlarged, globular, with apparently two 
subperitoneal nodules. On account of the general his- 
tory no examination of scrapings was thought necessary. 
At operation an advanced adenocarcinoma of the corpus 
was found. (3) Here a globular mass projected from 
the right side of the uterus and from the vicinity of the 
right comu a subperitoneal nodule. Both uterus and 
nodules were movable and a diagnosis of intraligamentous 
and subperitoneal myomata made. At operation the 
subperitoneal nodule proved to be a tense and kinked 
hydrosalpinx, the intraligamentary growth an adeno- 
carcinoma of the ovary invading the bladder wall. (4) 
This patient, aged sixty, presented temperatures from 
100 to 103°. There was marked pain in the pelvis and 
slight discomfort in defecation. In the vaginal vault, 
and apparently attached to the posterior surface of the 
uterus, was a slightly irregular but globular mass. The 
diagnosis was between adhesions of subperitoneal myoma 
glued to the pelvic floor and pelvic abscess. Operation 
showed an irregvilar globular tumor involving the sigmoid 
flexure. This had dropped over to the right side and 
become adherent to the pelvic floor. Diverticulae were 
filled with fecal concretions, and between the floor and 
the growth was a small abscess due to rupture of a diver- 
ticulum from the intestine. The tumor was benign. 
(5) A case of adenocarcinoma of the kidney had been 
well for sixteen months after operation. Then a rapidly 
growing tumor was noticed in the hepatic region, which 
turned out to be a neoplasm involving the lower half 
of the liver, but was not a metastatic growth. 

Injury to the Rectum in Gynecological Examinations. — 
Dr. H. A. Kelly of Baltimore called attention to 
the importance of the rectum as an avenue of investigation 
and the obstacles encountered by this route. A rough 
examination might readily rupture cystic structures and 
spread their contents over the abdomen. He had also seen 
several cases in which the finger was pushed through the 
rectum and entered the abdominal cavity, necessitating 
repair by laparotomy. In one instance it was found that 
a large ovarian cyst had been punctured. The accident 
depended not so much on the rough handling or careless- 
ness of the examiner, as on the soft and friable character 
of these tissues. In making a rectal examination, it was 
always well to recognize, but not to invaginate the am- 
pullae and to get the finger beyond what might be called 
the third sphincter of the rectum. During an examina- 
tion it was most essential that the arm be perfectly re- 
laxed, and the wrist not held stiffly. Distending the 
bowel with air also greatly facilitated the examination. 
When injured, the rectum might be repaired through the 
posterior cul-de-sac, or, if advisable, by the abdominal 
route. He asked that cases of this kind be put on 
record. 

Dr. Wetherill of Denver called attention to the possi- 
bility of injuring the rectum during the conduct of a labor, 
when the operator's finger was inserted into the rectum 
to support the advancing fetal head. Dr. Cullen of 
Baltimore reported two cases in which the rectum had been 
injured. Dr. Shoemaker of Philadelphia mentioned an 
instance in which an appendical abscess had been ruptured 
by the hydrostatic pressure of an enema, and Dr. Noble 
of Philadelphia also reported a case of pelvic abscess 
ruptured by rectal examination. 



Some Further Observations on the Use of the Stem 
Pessary for Scanty and Painful Menstruation. — Dr. J. H 
C.^RSTExs ot Detroit stated that in a certain class of cases 
these conditions could only be ascribed to lack of exercise 
of the uterine muscle. He thought that the organ could 
be sufficiently well developed by the introduction of a 
foreign body which the uterus would constantly endeavor 
to expel. In another class of cases, dysmenorrhosa comes 
on later, after normal menstruation for years, in which the 
uterus, and especially the cervix, had undergone premature 
atrophy. All these cases might be relieved by the intro- 
duction of a stem pessary. In one of his cases the stem 
had been in place for two years, but after removal a 
gradual return of her symptoms took place, which was 
finally relieved by the reintroduction of the instrument. 
In another case of sterility of five years' standing, preg- 
nancy came on after the use of the stem for a few months. 

The Propriety, Indications, and Methods for the Termina- 
tion of Pregnancy. — Dr. F. A. Higgi.ns of Boston believed 
that there were evidences of broadening of the indications 
for the termination of pregnancy, and the wisdom of this 
could not be questioned. The question remained whether 
this would lead to ill-advised abortion, but he felt safe in 
stating that he did not think it would. He discussed in 
detail the influences exerted by the various acute and 
chronic diseases. An acute disease was not usually an 
indication, but if labor comes on, it should be hastened. 
The religious question was also touched upon. 

As for the methods, he considered bougies favorable in 
certain cases, but thought it better to employ two than 
one. He recommended, however, the Vorhees bag and 
the colpeurjTiter. Manual dilatation was accompanied 
by the danger of rupture. Instruments, he claimed, were 
under more complete control, and therefore more secure. 
The dilatation in each case depends on the amount of 
stretching which the cervix ■will endvu-e. The Bossi 
dilator was shown and discussed, and the author's newly 
modified instnoment presented. This was more compact 
than the Bossi and claimed to be less dangerous. It might 
also be used for dilating the cervix before ordinary 
curettage. 

Dr. H.\ll of Kansas City said that he thought it was 
more honorable to suggest methods of preventing preg- 
nancy in questionable cases rather than to devise methods 
of abortion. He believed that the effect of such a paper 
might be bad on the public mind. Where the necessity 
existed, he considered that the instrument was preferable 
to the use of the fingers. 

Dr. B.\co.Nr of Chicago claimed that the social condition 
of the patient should be largely taken into account in 
deciding the advisabiUty of abortion. In the case of 
hydramnion and twins, he advised rupture of the mem- 
branes, and the bag, when used, should then be placed 
within the egg sac. In his opinion, vaginal cssarean 
section was to be preferred to the use of instruments. 

Adherent Uterus as a Complication of Labor. — Dr. J. C. 
Appleg.ate of Philadelpliia discussed the circumstances 
imder which the pregnant woman with adherent uterus 
should be allowed to go to full term, and the best method by 
which such complications could be treated. He found 
that the round ligament suspensory operations had no 
effect, but that labor quite fully destroyed the results of 
the previous operation. Peritoneal suspension was dan- 
gerous from possible ruptxu^ of the uterus. Ventral fixa- 
tion was unjustifiable before the menopause, except tinder 
rare circumstances. Before attempting the latter opera- 
tion, amputation of the cen-ix should always be done. 
In vaginal fixation he believed that labor should be in- 
duced. With ventral fixation, pregnancy to full term 
depended on the mobilit}' of the uterus; if the cervix failed 
to enlarge and rose posteriorly, labor should be induced. 
The safest thing for these cases, however, was considered to 
be cesarean section. In the reader's estimation the best 
method of suspending the uterus was by sutures intro- 
duced in front of the origin of the tubes instead of to the 
fundus. Two cases were reported, in one of which the 



July 2, 1904] 



MEDICAL RECORD. 



37 



adherent uterus was the cause of pernicious vomiting, and 
mechanical intestinal obstruction. Labor was induced at 
seven months, and was accompanied by uterine inertia 
and post-partum hemorrhage. The cause of the adhesion 
had been parametritis following a previous abortion. In 
the other case there was an adherent uterus following 
ventrofixation, perineorrhaphy, and amputation of the 
cervix, thirteen months pre\-iously. 

Dr. Dunning of Indianapolis stated that he had done 
suspensory operations in 165 cases, eight of which became 
pregnant and terminated the same without complications. 
He suspended the uterus by three sutures, which formed one 
band between the organ and the anterior abdominal wall. 
Dr. Fry of Washington had 150 cases, with fifteen 
cases of pregnancy, without complications and without 
any subsequent return of the prolapse. He thought 
the Alexander operation unsuitable, as it was apt to be 
followed by dragging on the round ligaments. 

Membranous Endometritis. — Dr F. F. L.\wrence of 
Columbus referred to unsatisfactory results obtained 
from local treatment in this condition and proposed more 
radical measures. In forty-two cases seen he noted that 
tubal or ovarian disease were almost always present. In 
a considerable number the ovarian disease appeared to 
have followed the exanthemata. He belie\-ed that mem- 
branous endometritis was probably a secondary trophic 
disturbance due to the presence of an intercurrent pelvic 
disease, and suggested that when the condition of the 
tubes and ovaries was not due to infection, a cure of the 
endometritis might be secured by removing the diseased 
structures without in any way treating the uterus itself. 
He had successfully accomplished this result and rec- 
ommended further and more extended trials. In all 
cases of membranous endometritis, which he considered 
a more appropriate term than membranous dysmenor- 
rhoea, a careful examination should be made with these 
points in view. 

Dr. Fischer of Philadelphia thought the expulsion 
of shreds only not sufficient evidence to warrant the 
diagnosis of membranous endometritis, and said that 
among a large number of cases he had only observed two 
instances of this disease. He marvelled at the large 
number of cases observed by the writer. 

Dr. Lawrence said that he did not propose this as an 
absolute recommendation, but offered it as a suggestion 
which had been borne out by facts. Many of his cases 
had expelled complete casts; but even the presence of 
shreds, he claimed, was sufficient to stamp the condition 
as a true membranous endometritis. 

Management of the Acute Infective Stages of Abdominal 
Inflammation. — Dr. G. E. Shoemaker of Philadelphia 
read this paper, which might be summarized as follows: 
in some acute abdominal inflammatory types of disease, 
operate radically unless there is good reason for the 
contrary. As an example of this, he quoted appendicitis. 
In other types do not operate radically in the acute stage, 
unless there is good reason for the contrary, but operate 
in subacute or the chronic stage. Example of this was 
gonorrhoeal salpingitis. Individual cases of all types 
of disease should be watched by a trained eye, as disaster 
was apt to follow any fixed rule. He concluded by 
noting the signs which point to operation and also measures 
useful in non-operative cases. 

The officers of the section for the ensuing year, as 
selected by the Committee on Nominations, were as fol- 
lows; Chairman. Dr. C. L. Bonifield of Cincinnati; Vice- 
Chairman, Dr. F. F. Lawrence of Columbus; Secretary. 
Dr. Manton; Delegate, Dr. J. W. Bovee of Washington. 



SECTION IN SURGERY. 

Third Day — Thursday, June 9. 
The Anatomy of Inguinal Hernia; Andrew's Operation 
for Radical Cure. — Dr. D X. Eise.vdr.\th of Chicago 
dealt with the general considerations on the anatomy of 



this subject, which he demonstrated by a very ingenious 
model explaining the objects to be accomplished by a 
radical cure. He gave his experience with the Andrew's 
operation and freely illustrated his paper by models 
and charts. 

Three Years' Experience with the Autoplastic Suture 
for Hernia. — Dr. L. L. McArthur of Chicago gave a 
final report of his experience with this suture, and stated 
that three years' experience with its use in inguinal hernias 
encouraged the continuance of its employment. As a 
result of trying it in ninety-three cases and as judged by 
the histological findings in experimental work, he was 
justihcd in claiming that the transplanted tendon lived. 
He demonstrated this fact by an examination of the scar 
of a patient dead of a subsequent appendicitis a year 
after having an autoplastic suture. 

Surgery of the Trifacial Nerve and Its Ganglia. — Dr. John 
B. Murphy of Chicago went very fully into this subject, 
which he divided into five stages: (i) Resections of 
branches down to the cranial foramina. (2) Division 
of branches within the cranium, with efforts to occlude 
the foramina. (3) Removal of the Gasserian ganglion, 
with intracranial segments of nerve. (4) Extraction 
of sensory root, and ; (5) intraneural injections, and 
made clinical reports with the result in eleven cases 

Intracranial Neurectomy for Trigeminal Neuralgia, 
Cases and Comments. — Dr. Harry M. Sherman of San 
Francisco gave a brief report of five operations on four 
patients, in three of which uneventful recoveries from the 
pain were secured. He mentioned some slight modifica- 
tions in the incisions of the soft parts and of the bone, and 
recommended the pouring of salt solution into the skull 
before the suture to fill all vacant spaces and exclude the air. 

Summary of the Final Results of Four Cases of Division 
of the Sensory Root for Tic Douloureux. — Dr. Charles 
H. Frazier of Philadelphia spoke of the theoretical 
advantages of this method over operative procedures and 
showed the immediate results obtained. He claimed to 
have had no evidence of recurrence, one, two, and three 
years after operation. 

Dr. Charles K. Mills of Philadelphia, Dr. Walter 
G. Spiller of Philadelphia, Dr. Robert F. Weir of New 
York, Dr. J. Shelton Horsley of Richmond, Va., Dr. 
Cushing of Baltimore, and Dr. John B. Murphy of Chicago 
discussed these papers from \arious points of view, the 
general conclusions being that the relief of the condition 
was not as yet an assured fact by any of the methods 
mentioned, and Drs. Sherman, Murphy, and Frazier 
closed the discussion. 

Laminectomy: A Further Contribution. — Dr. John C. 
MuNRO of Boston reported from twenty-five to thirty 
cases of laminectomy and pleaded for the simplification 
in the technique as being important in reducing the 
severity of the operation. 

Dr. Lund of Boston and Dr. Cushing of Baltimore 
complimented the author on his excellent results and 
heartily endorsed the points he made. 

Treatment of Cold Abscesses and Sinuses in Tuberculous 
Disease of Bone. — Dr. V. P. Gibney of New York 
took up the routine surgical treatment of the day and 
dwelt extensively on the orthopedic treatment, bacterio- 
logic findings, value of asepsis from beginning to end, and 
comparative results of the methods employed. 

Old Unreduced Dislocations. — Dr De Forest Willard 
stated: (i) Early immediate diagnosis was the most 
important element in the prevention and treatment of all 
dislocations. With ether, the «-ray and anatomical and 
surgical knowledge, the displacement should always have 
been discovered by the surgeon. His only excuse for 
non-recognition would have been extreme injury in other 
portions of the body. (2) An unrecognized or unreduced 
dislocation should have been carefully examined under 
ether to discover the extent of adhesions and the possibiHty 
of affecting reduction without measures; failing in this, 



38 



MEDICAL RECORD. 



[July 2, 1904 



continuous extension in he^ should be practised for several 
weeks; the second attempt, without the application of 
extreme force, should be made, the permission of the 
patient having been previously obtained to permit of open 
operation if deemed necessary. (3) Open section should 
include the division of all muscular, tendinous, capsular, 
and bony obstacles to reduction. When the socket is 
filled up with dense fibrous tissue, such tissue should be 
excavated and the head of the bone displaced iit situ. 

(4) Partial or complete excision of the head and of 
fragments in case of fracture, was frequently necessary. 

(5) In cases that had existed more than a year, or in which 
the original injury had been extreme, operation should 
be avoided unless pressure upon nerves or blood-vessels 
was seriously impairing the usefulness of the limb or 
giving pain. Resection should be reserved for bad late 
cases with pain and serious nerve symptoms. Sepsis 
was frequent on account of the severity and length of the 
operation. (6) Pain and disability were the two most 
important measures in arriving at a decision concerning 
operation. When a limb was useful in its new position, 
gave no pain or difficulty, it should be left alone. (7) 
In the after-treatment, muscular gymnastics, electricity, 
and massage were very important measures and sl»uld 
be persistently employed. 

Conservative Perineal Prostatectomy: Report of Fifty 
Cases. — Dr. Hugh H. Young of Baltimore called es- 
pecial attention to the absence of mortality and the 
simplicity of the procedure, many of the patients being 
over seventy-five and some over eighty years of age, and 
laid stress on the importance of cystoscopy and careful 
preliminary treatment. 

Prostatic Obstruction. — Dr. Parker Sv.ms of New York 
read a fully illustrated paper on this subject. 

Prostatectomy in General, Especially by the Perineal 
Route. — Dr. George Goodfellow of San Francisco gave 
the indications for his adherence to the perineal route, 
described his method of operating, referred to the mor- 
tality in seventy-five cases operated upon by this 
method, and gave the ultimate results of each. 

Is It Wise to Try to Make Any One Operative Method 
Apply to All Prostatectomies? — Dr. Eugene Fuller < ! 
New York read a paper so entitled, which he opened by 
stating that the results obtained by prostatectomy had 
put the operation on a firm footing. Numerous surgical 
makeshifts were brought forward, when the operation was 
first introduced, to compete with the radical operation. 
Most of these had now been discarded, owing to the un- 
satisfactory results attending them and to the increasingly 
better results following prostatectomy at skilled hands. 
The criticism was ma<le that most of the present ■writers 
on the subject concerned themselves only with the prob- 
lem of operative removal of the prostate, the questions of 
after treatment and general management receiving little 
or no attention. All prostatectomies were grouped under 
three headings: (i) W'here the hypertrophy is removed 
through the employment of a suprapubic cystotomy ; (2) 
where it is removed through the employment of a perineal 
cystotomy; and (3) where it is extracted along the path 
of a perineal dissection, the aim of which is to avoid 
opening the urinary tract or the rectum. As far as the 
mere removal was concerned, he stated that it could be 
done by any one of the three methods, and then discussed 
the pros and cons of the different methods, but few cases 
were found in which the third method seemed ad\isable. 
When performed according to Dr. Fuller's ideas the second 
method was ad\ocated for most cases in connection with 
which there existed good expulsive force to the bladder. 
Where this was impaired and where serious lesions of the 
urinary tract existed the suprapubic operation was the 
one usiially chosen. He called attention to the fact 
that most writers showed a strong tendency to try to 
make some special form of the perineal operation apply 
to all cases and to entirely discard the suprapubic opera- 



tion on the ground that it was either unnecessary or 
operatively extrahazardous. These objections were ably 
met. The suprapubic operation, it was asserted, should 
in itself give no extra mortality if certain rules were ob- 
served in its performance, if the incision was properly 
sutured and drained, and if the surgical supervision of the 
after-treatment was efficient. The value of the supra- 
pubic vesical drainage vent, a feature connected with the 
suprapubic operation, was especially dwelt upon. The 
establishment of such a vent. Dr. Fuller stated, decided 
him to choose the suprapubic operation in a certain class 
of cases. In conclusion, a protest was entered against 
classing as true prostatectomy cases of middle-aged or 
even younger men which represented simple inflammatory 
effusions in connection with the prostate or its periphery. 
In such cases an operator attempting prostatectomy would 
find nothing to enucleate, or for that matter to remove. 

Dr. Orville Horwitz of Philadelphia, Dr. Robert H. 
M. Dawbam of New York, Dr. John C. Munro of Boston, 
Dr. Martin B. Tinker of Cornell, Dr. D. N. Eisendrath of 
Chicago, and Dr. Archibald McLaren of St. Paul freely 
discussed these papers and endorsed most of what had 
been said, the authors closing. 

Kidney Stone; Diagnosis and Treatment. — Dr. Arthur 
D. Bevan of Chicago took up the question of etiology, 
symptoms, differential diagnosis, prognosis, technique of 
operative procedures, and the question of recurrence after 
operation. 

Fourth Day — Friday, June 10. 

The Treatment of Fractures of the Patella by Lateral 
Sutures. — Dr. Jos. A. Blake of New York dwelt fully on 
the anatomy of this subject and reported the resiilts of 
eighteen operations both as to union and as to function 
according to his method. 

Surgical Treatment of Certain Cases of Arthritis Defor- 
mans. — Dr. Martin B. Tinker of Ithaca, N. Y., presented 
this paper and stated before beginning a discussion|on this 
subject that it was necessary to keep in mind the exact char- 
acter of the disease under consideration. He said the 
condition was not a subacute or chronic rheumatism or 
tuberculosis, but a distinct diseased condition character- 
ized by its long course, with progressive involvement c f 
many joints, which lead eventually to absolute disability 
from ankylosis. Many interesting suggestions, he stated, 
had been made as to the etiology of the affection. In some 
cases it followed severe nerve-strain, and the nervous ele- 
ment was no doubt an important factor. Disturbance of 
metabolism, he stated, was also always present, but these 
were probably only contributing factors. The infectious 
origin seemed most probable, as several cases had been 
observed in which the disease had developed directly 
after a severe infection. He stated pain, swelling, and 
stiffness of the joints were the most important symptoms; 
the pain gradually ceased as the joints became fixed. The 
swelling at first was from effusion, but this would soon dis- 
appear, and later the enlargement was from bony or fibrous 
thickening. He stated that the use of tuberculin was of 
great value in the diagnosis in distinguishing it from tuber- 
culosis, a condition with which it might be confused. He stat- 
ed that in the treatment both palliative and operative meas- 
ures should be considered; as a rule, the general principle 
followed in the treatment of joint trouble, to put the joint 
at rest, was reversed, for if the joint was kept quiet, 
stiffening was certain to occur at once. Gymnastics, 
massage, and passive motion were to be judiciously em- 
ployed; baking at from 280' to 350° Fahrenheit was of 
value, as were also the use of various forms of baths; 
general hygienic measures were also of importance. In 
the operative treatment forced motion under ana:'Sthesia 
was condemned, for the stiffness was not from adhesions, 
but from bony deposits and change of the contour of the 
bones affected. Arthrotomy and excision of osteophytic 
deposits might be employed where the stiffness of the 



July 2. 1904] 



MEDICAL RECORD. 



39 



joint was dependent upon the pressure of only one or two 
such bony prominences that lock the joint and where the 
acute symptoms had entirely subsided. Excision of the 
joint was indicated in cases of complete ankylosis, to 
restore motion, and often enabled the patient to feed and 
dress himself and perform other necessary duties impos- 
sible with an ankylosed joint. He stated that operative 
treatment was limited to a comparatively few cases of 
this kind. The condition was generally a most pitiable 
one and the general condition was incvu-able. 

Impacted Fractures of the Neck of the Femur. — Dr. 
Le Movne Wills of Los Angeles reported two interesting 
cases, which he illustrated with radiographs. He laid 
particular attention on the marked difference in treatment 
jn each case and to the good results obtained. 

Fat Embolism of Lung, Following Fracture, with Report 
of Two Cases. — F. Gregory Coxxell, M.D., of Leadville, 
Co!., reported two cases of fat embolism of the limg which 
followed fractures of the long bones, both of which recov- 
ered. In a study of the history of the subject he found 
that about 250 cases had been reported, and of these not 
over a dozen had been contributed by American writers. 
The anatomy of the parts involved was reviewed, and 
among the causes other than fracture are envimerated 
orthopedic operations, open operations upon bones and 
joints, surgical operations on structures other than bone, 
inflammation of bone or periosteum, laceration, bruising 
or suppuration of the fat containing soft parts, or exten- 
sive bums or scaldings, rupture of fatty liver, and also 
causes that had arisen within the circulation, such as 
atheromatous changes of the vascular wall, fatty changes 
of the thrombi of various origin and location, diabetes, 
icterus, etc. The symptomatology was considered at 
length; the milder form was rarely diagnosed, and was 
of little import; the acute and rapidly fatal form was 
rarely differentiated from shock, and was often unsus- 
pected. The ordinary form of fat embolism, that was 
recognized as such, usually presented the following symp- 
toms : An interval of euphoria ; lipuria or fat in the 
sputum; extreme debility, anxiety, malaise, somnolence, 
pallor, cyanosis; respiration, rapid and irregular, with 
dyspnoea, cough, pain, hsmoptysis, rales, oedema, or con- 
solidation; pulse, feeble, irregular, and rapid; temperature 
unreliable; loss or diminution of sensibility, and of the 
reflexes, pupils contracted, Cheyne-Stokes respiration, 
spasm, convulsion, vomiting, paralysis of coma. Each of 
these are considered pro and con, but the temperature, 
which was perhaps the most perplexing and unsettled 
symptom of fat embolism, was gone into at length, and 
it was concluded that the temperature might be high — in 
thirty -seven cases in which the temperature was given, 
that were collected from the literature, twenty-nine had 
an elevation of the temperature, while in the eight the 
temperature was mentioned as being either normal or 
subnormal. The diagnosis during life was first made by 
Lucke, and in the same year, 1S73, by Bergman; the first 
in America to diagnose the condition during life, was 
the late Christian Fenger. in 1879. Among the conditions 
more likely to be confused with fat embolism might be 
mentioned: Shock, septicsemia, pulmonary embolism, and 
less commonly, the effects of anaesthetics, congestion of 
the Ituigs or kidneys, cerebral hemorrhage, concussion of 
the brain, atheroma of the coronary arteries. The prog- 
nosis was most uncertain, owing to the fact that the 
frequency of the condition was tmknown. Fat embolism 
of a greater or lesser degree followed practically all frac- 
tures, but it gave rise to serious symptoms comparatively 
seldom. The fat in the circulation had no deleterious 
effect upon the blood; its sole action was a mechanical one, 
in obstructing the capillaries. The treatment was un- 
satisfactory — in fact, it might be said that there was no 
treatment. Prophylaxis would consist of gentle handling 
of the limb, so as to rupture as few fat cells as possible, 
and then immobilization. After the symptoms were 
present, drainage, as it lessens the tension at the site of 



the injury, might be of advantage. But the closest at- 
tention should have been given to the heart, and as the bulk 
of the fat was eliminated through the kidneys, attention 
should also have been given to these same organs. 



ClN'ClNN.\TI AC.\DE.\IY OF MeDICINE. 

At a regular meeting of the Academy, held on April iS. 
Dr. B. Merrill Ricketts presented four cases. A case of 
excision of the elbow-joint for ankylosis with an excellent 
result and three cases of hernia, one a double inguinal 
hernia with perfect result and two cases in which three 
operations had been necessary before a good result was 
secured. Dr. Ricketts laid the failure of the first two 
operations in each case to the use of faulty sutures. Dr. 
Edwin Ricketts showed a tube and ovary removed from a 
woman in the chilcVbearing period. She had had several 
attacks of severe pain with some bloody discharge from the 
uterus. On removal, the tube was found distended with 
blood and was believed to be an extrauterine pregnancy. 
Microscopical examination had not yet been made. 

The paper of the evening was read by Dr. John E. 
Greiwe entitled, "Aortic Lesions." He said in brief: 

Our greatest advance in the comprehension of aortic 
lesions has come from the study of their etiology, and we 
will do most good by using this knowledge in their pro- 
phylaxis and treatment. Lesions of the aortic orifice 
are always of grave importance and are always very 
difificult to manage. The increase of blood pressure in 
the left ventricle with the necessary increase of labor 
involved the tendency to degeneration of the muscular 
wall, the greater danger of cerebral involvement and the 
frequent involvement of the mouths of the coronary 
arteries are some of the special dangers of these lesions. 
In these cases we must study not the heart alone but the 
condition of the whole circulatory system and the remote 
organs. Of S54 autopsies at the Cincinnati Hospital, 160 
showed well-marked heart lesions, 43 involved the mitral 
valves alone, 42 the aortic valves alone. In 38 both 
mitral and aortic valves were diseased. In two cases the 
tricuspid valves were diseased in combination with disease 
of the mitral and aortic valves. Sixteen cases showed peri- 
carditis, 10 with adhesions; of these 10, five were asso- 
ciated with aortic disease and two with mitral. The 
remaining 19 cases showed muscular change or disease of 
the coronary arteries. These figures show the relative 
frequency of aortic and of combined lesions. 

Known causes of aortic lesions are acute infections, 
especially acute theumatism and scarlet fever, alcoholism, 
syphilis, gout, hard manual labor, sudden severe strain, 
lead poisoning, nephritis, excessive use of coffee and 
tobacco, chronic intestinal autointoxication, and last but 
not least, conditions that give rise to long continued and 
oft repeated high tension in the circulatory apparatus. 
Chronic poisoning from whatever cause destroys the 
elasticity of the blood-vessels, hard labor and long con- 
tinued stimulation by coffee, tea, and tobacco cause high 
tension and later impair the elastic coats of the vessels. 
Sudden strain may cause n.ipture of valves with regurgita- 
tion and sudden collapse. Of all causes or associated 
conditions, nephritis is most important, and of 160 cases, 
89 showed marked kidney change, mostly interstitial, but 
parench\-matous changes and pj-elonephritis were not 
micommon. The importance of uranalysis in these cases 
and the good effects of diet and eliminative treatment are 
well loiown. 

In regard to long continued and oft repeated high 
tension, there can be httle doubt that the heart re- 
sponds to all the emotions of the central nervous system, 
and the writer believes that profound emotions, such as are 
almost constantly present in cases of hysteria, neuras- 
thenia, melancholia, etc., are frequently, by raising the 
blood pressure, responsible for disturbances which at first 
may be purely fvmctional. but later may produce organic 
changes in the blood-vessels and secondarily in the heart 
itself. 



40 



MEDICAL RECORD. 



[July 2, 1904 



The real etiology and patholog^y of these cases is still 
Tincertain, but it is certain that long continued high tension 
leads to a loss of elasticity in the middle coat of the arteries 
with changes in the intima and tremendous backdamming 
on the aortic valves. No fruits may be present for a long 
time, but the second aortic tone is much accentuated and 
tachycardia is frequent. 

The writer has taken sphygmographic tracings and 
■measurements of blood pressure in a number of these 
■cases. Miss C, thirty-four years, suffering from neuras- 
thenia, has very high blood pressure with the Riva Rocci 
instrument, 228; Gaertner, 200; and Basch 215. Pulse 88, 
second aortic tone much accentuated. Elastic waves 
are poorly marked in the tracing, showing loss of elasticity. 
Miss S., age thirty, also suffering from neurasthenia with 
"high tension. Pulse 116, Riva Rocci 133, Basch 120, and 
Gaertner no. In this case the fiftt aortic tone was 
roughened and the second accentuated, the elastic waves 
■of the tracing were diminished. The patient is subject 
to attacks of tachycardia with semi-consciousness and 
lividity. Both tracings show the "ptilsus tardus" of high 
pressure. Other sphygmograms from aortic lesions were 
■shown, showing well-marked "pulsus tardus," and in one 
instance "pulsus rotundo tardus" due to high tension and 
loss of elasticity in the blood-vessels. In one tracing a 
•well-marked "water-hammer pulse" was shown. 

As regards treatment, prevent the trouble as far as 
possible by treating the predisposing conditions. When 
the trouble has begun prevent further damage by attention 
to diet, hygiene, medication, and regulation of the work 
to be done. Avoid strain, physical and I'nental. As 
said above, high pressure is often responsible and should 
1)6 relieved by attention to the kidneys, and often the 
intestinal tract will be found to l)e the exciting cause. 

Venus stasis should be relieved by mild exercise or 
passive movements, and systematic breathing exercises 
should be carried out. The Nauheim treatment relieves 
liigh tension by bringing about a freer flow through the 
capillaries, and can be carried out at home by the use of 
3. powder prepared for the author in this city. 

Following the paper. Dr. Greiwe demonstrated a 
number of pathological specimens from the Cincinnati 
Hospital Museum and several instruments for measuring 
Islood pressure. 



While the Medical Rkcord is flcasci to receive all 
new {Publications which may be sent to it, and an acknowl- 
edgment will be promptly made of their receipt under this 
heading, it must be with the distinct understanding that 
its necessities are such that it cannot be considered under 
obligation to notice or review any publication received by 
it witich in tlie judgment of its editor will not be of interest 
to its readers. 

Beitrage zur Klinik der Tuberkulose. Herausge- 
geben von Dr. Ridoi.ph Bracer. Band 2, Heft 4. 8vo, 
pp. 251-364. A. Stuber, Wurzburg, Germany. 

Obstetrics and Gynecolooic Nursing. By Edward 
P. Davis, A.M., M.D. Second edition, revised. i2mo, 
402 pages. Illustrated. Muslin. W. B. Saunders & 
Company, Philadelphia. Price, $1.75 net. 

Epilepsy and Its Treatment. By William P. 
Spratling, M.D. 8vo, 522 pages. Illustrated. W. B. 
Saunders & Company, Philadelphia, Pa. Price, cloth, 
44 net. 

American Edition ok Nothnagel's Practice: Tuber- 
culosis AND Acute General Miliary Tuberculosis. 
By Dr. G. Cornet. Edited, with additions, by Walter 
B. James. M.D. 8vo, 806 pages. Muslin. M. B. 
Saunders & Co., Philadelphia, Pa. Price, S5 net. 

Clinical Treatises on the Pathology and Therapy 
OP Disorders of Metabolism and Nutrition. By 
Prof. Dr. Carl VON NooRDEN. Part V. i2mo, 92 pages. 
Muslin. Edited by Boardman Reed, M.D. E. B. Treat 
& Company, New York. 

Beitrage zur Pathologie und Therapie der Pan- 

KREASERKRANKUNGEN MIT BESONDERER BeRUCKSICHTI- 

GUNG DER Cysten UND Steine. Von Privatdocent Dr. 
Paul Lazarus. Band 51 und 52. 8vo. 208 pages. 
Illustrated. August Hirschwald. Berlin. 



Mthiml Strata. 

Contagious Diseases — Weekly Statement. — Report of 
cases and deaths from contagious diseases reported to 
the Sanitary Bureau, Health Department. New York 
City, for the week ending June 25, 1904: 



Measles 

Diphtheria and croup 

Scarlet fever 

Smallpox 

Varicella 

Tuberculosis 

Typhoid fever 

Cerebrospinal meningitis 



Casa 



Deaths 



464 


3' 


455 


35 


181 


21 


I 




57 




,1/0 


171 



Health Report. — The following cases of smallpox, 
yellow fever, cholera, and plague have been reported 
to the Surgeon-General, U. S Marine Hospital Service, 
during the week ended June 25, 1904: 



SMALLPOX — UNITED STATES. 

Colorado, Denver Apr. 16-May 2S. 

Delaware. Wilminijton June r 1-18 

Florida, Jacksonville June i i-i8 

Georgia. Macon June 11-18 

Illinois. Chicago June ii-i8 

Louisiana, New Orleans June i x-i8 

Maryland. Baltimore June 11-18 

Michigan. Detroit June 1 1-18 

Missijuri. Saint Louis June 4-18 

Nebraska, Omaha June 1 1-18 

South Omaha June i i-i 



CASES DEATHS 
14 



New Hampshire. Manchester June 11-18. 

New York, Buffalo June n-i8. 

Ohio, Cincinnati June 3-17 ■ 

■!" 

-Ju 
.lu 
■ Ju 

.Ju 

•J" 



Dayton June 1 1-18. 

Hamilton June 7-14. 

Pennsylvania. Altoona June 11-18. 

Philadelphia June 11-18. 

South Carolina. Charleston June 11-18. 

Tennessee, Memphis June 11-18. 

Nash\'ille June 1 1-18. 

Wisconsin, Milwaukee June 1 i-i8. 



33 
106 



SMALLPOX — INSUL.\R. 

Philippine Islands, Manila April 30-May 7. 

S.MALLPOX — FOREIGN. 

Austria, Pra;:iue May 

Belgium, Antwerp May 

Rrazil. Pemambuco May 

Rio de Janeiro May 

Canada, Vancouver May 

France. Lyons May 

Paris May 

Gibraltar May 

Great Britain, Birminsham May 

I Bradford May 

Bristol Mav 

Cardiff May 

Dundee May 

Edinburfih May 

Glasgow June 

Hull May 

Liverpool May 

London May 

Manchester May 

New-Castle on-Tyne May 

Nottingham May 

India, Bombay May 

Calcutta May 

Karachi May 

Italy, Milan April 

Palermo May 

iapan, NaKasaki May 
texico. City of Mexico May 

Vera Cruz May 

Netherlands, Amsterdam June 

Panama, Panama June 

Russia, Moscow May 

Odessa May 

Warsaw April 

Turkey, Constantinople May 

YELLOW FEVER. 

Brazil, Rio de Janeiro May 8-2j 19 S 

Mexico, Merida June s- 1 1 i 

Tehuantepec June 5-11 S » 

Vera Cruz May 28-June 4 3 



Hawaii, Honolulu June 10 

Philippine Islands, Manila April jo-May 7. 




-June 4 • Imp'ted 



40 
3 



PLAGUE — FOREIGN'. 



Egvpt May 14-21- 

India, Bombay May 18-24- 

Calcutta May 14-21 . 

Karachi May 15-22. 



36 



87 



36 
160 
134 

79 



CHOLERA. 



India, Calcutta May 14-21 

Madras May 14-'° 



Medical Record 

A Weekly Journal of Medicine and Surgery 



Vol. 66, No. 2. 
Whole No. 1757. 



New York, July 9, 1904. 



$5.00 Per Annoir. 
Single Copies, lOc. 



©rtgtnal Arttrl^H. 



ILLUMINATING GAS POISONING: A CLINI- 
CAL STUDY OF NINETY CASES.* 

By W. oilman THOMPSON, M.D., 

NEW YORK. 

PROFESSOR OF .MEDICINE IN THE CORNELL UNIVERSITY MEDICAL 

COLLEGE IN NEW YORK CITY. 

In view of the frequency and seriousness of poison- 
ing by illuminating gas, it is a surprise that the con- 
dition has not received more attention in medical 
literature, for it presents a number of interesting 
phenomena, such as an eccentric fever, a high degree 
of leucocytosis, and a large group of nerve symptoms, 
besides various practical problems. It has been my 
experience to meet with three fatal cases and a num- 
ber of others in private practice besides many in 
hospital service. The conclusions herewith pre- 
sented are based upon a study of ninety cases, a large 
proportion of which were treated at the Presbyte- 
rian Hospital in the service of my colleagues or 
myself. This series of ninety cases includes twelve 
in which autopsies were performed. None bvit com- 
atose cases have been included, and of the ninety 
cases only seventeen, or 18.8 per cent., were fatal. 

The lack of systematic nomenclature and cooper- 
ation in methods of securing the data of Health 
Board statistics in the large cities of this country is 
strikingly illustrated in an attempt to secure such 
data for this article, thus the condition under dis- 
cussion is variously classed under such titles as "coal 
gas poisoning," "asphyxia," "illuminating gas pois- 
oning," "poisoning by noxious gases," etc. For 
example, in the Philadelphia Health Board Annual 
Report for 1900, I was surprised to find only 
one case under the heading "poisoning by illum- 
inating gas," until I unexpectedly discovered in the 
same document five more cases under the somewhat 
indefinite heading "suffocation by gas." There 
were doubtless other cases similarly diagnosed. In 
Boston there have been as many as forty-three fatal 
cases in a year. In the Baltimore Health Board 
report for 1900, eleven cases are recorded under 
the title "asphyxia" from gas inhalation and 
sixteen more under "noxious gases," presumabh- 
illuminating gas in most instances. In Chicago, in 
1898, the Health Board reported forty-five deaths 
from asphyxia by gas, and there were a few more 
probable cases under dubious headings. This inac- 
curacy of reports makes impossible any attempt to 
secure accurate data upon a large scale. In New 
York Citv, in 1901, the Health Board reported ninety- 
nine suicidal (forty-two females, fifty-seven males), 
and 189 fatal, non-suicidal cases of illuminating gas 
poisoning, making the important total of 288. In 
Bellevue Hospital alone, during the first three months 
of 1904, thirty-two cases were treated, with six deaths. 
If the mortality ratio represents a fair average, there 
must be little short of 2,000 cases in all occurring 
each year in New York City, a number which empha- 
sizes the importance of more thorough study of the 



*A paper read at the meeting of the Association of 
American Physicians, May 10, 1^04. 



condition than it often receives. This great prepon- 
derance of cases in New York City is readily ex- 
plained by the prevalence of cheap gas fixtures and 
gas stoves in the tenements, and by the large annual 
arrival of ignorant pauper foreigners who have never 
used gas or who, through poverty and nostalgia, 
become despondent and suicidal. 

In 1900 W. Sachs,' in an important monograph, 
collected from the entire literature references to 420 
articles published up to that date upon illuminating 
gas poisoning, to which Alexander Panski^ added six 
more, bringing the list up to March 16, 1902. Many 
of these articles, however, are reports either of isolated 
cases or of purely experimental research. A few 
small series of cases have been published, but, in so 
far as I am aware, the present series is the most 
extensive from which an attempt has been made to 
draw comparative clinical deductions. 

The chief difficulty in the study of this type of 
poisoning lies in the impossibility of estimating the 
quantity of gas inhaled and the degree of its dilution, 
as well as the duration of the inhalation. 

The majority of hospital cases are brought to the 
hospital during the early morning hours. An igno- 
rant, careless, or drunken person goes to bed at night 
in a room in which there is a gas stove or gas jet 
with a loose cock or leaky pipe, the danger of which 
is unrecognized. Falling into a sleep, made heavy 
by fatigue or drunkenness, the patient, without 
awakening, becomes gradually asphyxiated, at first 
with a well-diluted mixture of gas and air, and later 
by almost undiluted gas. As coma deepens, the loud 
sterterous breathing of the patient, or the odor of 
gas escaping beyond the room, attracts the atten- 
tion of some early riser, who gives the alarm and 
sends the patient to the hospital. Hence it happens 
that a majority of the hospital patients are those 
who have been inhaling gas for six or eight hours in 
increasing strength, and who have probably already 
been in coma for at least four or five hours. 

In several instances the careless fiinging of a towel 
or coat over the gas-bracket just before the patient 
got into bed, caused a reopening of a gas-cock which 
had been turned off. Some of the most serious 
cases arose in connection with the use of gas stoves, 
the pipes of which usually discharge much more gas 
than those of single illuminating burners. There 
are a few other cases in the series among workmen 
who have been suddenly asphyxiated by almost un- 
diluted gas, or among those who, with suicidal intent 
have deeply inhaled the gas from a tube and have 
thus been suddenly overcome by it. 

Although, as stated, it is difficult to estimate the 
volume of gas inhaled in the series of cases reported, 
enough had been taken in almost every instance to 
render the patient comatose for at least an hour, if 
not much longer, after discovery. The minor effects 
of chronic gas poisoning in slight degree, such as 
anaemia, vertigo, various forms of indigestion, mus- 
cular weakness, etc., will not be dealt with in this 
discussion. 

Among the ninet}' cases of the series, twelve pa- 



42 



MEDICAL RECORD. 



[July 9, 1904 



tients were definitely known to have attempted 
suicide, and there were probably as many more who, 
upon recovery, were unwilling to acknowledge it. 
This is rendered the more probable from the pre- 
ponderance of young women among the patients. 
The patients comprise fifty-three females and thirty- 
seven males, and their ages ranged from four months 
to seventy years. 

In most of the cases of this series ordinary illumi- 
inating gas was inhaled, containing certain volatile 
hydrocarbons, besides from 5 to 10 per cent, of carbon 
monoxid, but in some cases water-gas was inhaled, 
containing from 20 to 30 per cent, of CO. It has 
been shown experimentally that one-tenth of one 
per cent, of CO, when inhaled, causes discomfort, 
restlessness and dyspncea, and between i and 2 per 
cent, may be fatal. It is well known that the gas 
forms a relatively stable compound with the 
haemoglobin of the blood, thus markedly interfering 
with the oxygen-carrying power of the red cor- 
puscles, but it also possesses a second, more im- 
portant, direct toxic effect upon the central nervous 
system of the nature of a narcotic and depressant. 
That it causes a displacement of the nascent 
oxygen of the red cells, and thereby deprives the 
tissues and nerve centers of the body of oxygen, is 
not a sufficient explanation of the clinical phenomena 
of illuminating gas poisoning. These phenomena, 
especially those emanating from the nervous system, 
are too complex to be accounted for otherwise than 
through some specific toxic influence of the gas itself 
upon the central nervous system. Moreover, these 
symptoms appear in cases in which there is still a 
large percentage of red cells unaffected by CO, and 
they often persist long after all CO has left the blood. 
For example, in Case 43, the red cells on the sixth 
day numbered 5,440,000 and the haemoglobin was 
95 per cent., yet the patient died two days later 
with apparently normal lungs, as well as normal 
blood. 

In Case 46, on the eighth day, the red cells num- 
bered 5,400,000 and the haemoglobin was 95 per 
cent. On the twcnt}'-first day the red cells were 
4,944,000 and the haemoglobin was 100 per cent., 
but the fever, leucocytosis (18,200), and a feeble 
state still existed. That the haemoglobin at this 
date was normal was proved by spectroscopic 
examination. 

The leucocytosis is a very important symptom. 
Most of the cases came under observation before the 
value of differential counts was appreciated, and 
some of them before even a general leucocyte count 
was in vogue, hence I am unable to offer differential 
counts. A general count was made in twenty-nine 
cases, in all but two of which a considerable increase 
above the normal was observed. In eighteen of the 
twenty-nine cases a leucocytosis above 18,000 was 
determined. Among adults the highest non-fatal 
cases registered respectively 44,000, 32,000, and 
31,000. In the mild case of an infant of four 
months, the count was 52,000, but it is naturally 
high in infancy. 

It is an interesting fact that in every fatal case in 
which a leucocyte count was made, it exceeded 
18,000, the two highest counts being each 50,000. 

The maximum leucocytosis is usually attained 
within the first twenty-four hours, but sometimes 
not for forty-eight hours. Afterward it subsides 
slowly, and in the more severe cases it persists more 
than a week and outlasts the coma and many other 
symptoms. A leucocyte count above 18,000 or 
20,000 is always a symptom of grave import, 
although it does not make the prognosis necessarily 
fatal, and even in fatal cases there may be a gradual 
s-.ibsdence of the number of white cells, as illustrated 



by Case 58, in which the leucocytes on succeeding 
days were counted as follows, commencing with the 
first: (1) 50,000, (2) 38,500. (3) 14,300, (4) 14,200, 
(5) 13,800, (6) 13,800. This patient died on the 
sixth day from bronchopneumonia. The following 
cases are cited in support of the above statements: 
Case 33. — Admission count, 22,000. Six days 
later leucocytosis (11,300). yet the coma lasted only 
eight hours and the temperature did not rise above 
101.5. 

C.^sE 46. — Leucocytosis lasted twenty-one days, 
during which time the patient remained either 
comatose or delirious, and the maximum tempera- 
ture was 103° F. The maximum leucocyte count 
was 21,800 and the minimum 13,800. The red cells 
and haemoglobin percentage, first estimated on the 
sixth day, remained normal. 

Case 45. — The admission count was 14,600. The 
following day it fell to 7,700, and the patient re- 
covered. 

Case 4. — The admission count was 44,000; two 
days later it fell to 15,000; coma lasted only one 
day, and the temperature did not exceed 10 1.5. 
On the sixth day the patient recovered. 

Case 62. — This patient was comatose for only 
three hours after the time of first exposure to the gas, 
yet the leucocyte count was 14,000. A differential 
count showed: polymorphornuclear cells 92.3 per 
cent., lymphocytes 3.3 per cent., large mononuclear 
cells 4.1 per cent., eosinophiles 0.3 per cent. 

Case 31. — The admission count was 13,500; the 
following day it rose to 21,200, and the patient died. 
in coma on the fourth day. 

In explaining the leucocytosis, no doubt some 
allowance should be made for the stasis in the 
peripheral vessels accompanying cyanosis, but that 
this is not the sole cause is demonstrated by the fact 
that leucocytosis is observed in mild cases with 
vigorous pulse and no cyanosis, and in other cases it 
persists after cj'anosis has disappeared. It cer- 
tainly does not accompany, as in hemorrhage, a 
numerical loss of the red cells, for they remain normal 
in number, and, moreover, it often exceeds in degree 
the leucocytosis of that condition. It would appear 
to be a justifiable conclusion that it is due to some 
specific action of the gas, such as may occur in 
ptomain poisoning. (In a case of the latter 
toxaemia 1 have records of a leucocytosis exceeding 
15,000.) 

I am indebted to Dr. Herbert S. Carter for an- 
analysis of the chlorides and urea of the blood in 
five non-fatal cases. According to Halliburton' the 
average percentage of chlorides in normal blood is: 
sodium chloride 0.27, potassium chloride 0.205; 
total chlorides 0.475. In Carter's cases the total 
percentage was as follows: (i) 2.5, (2) 1.4, (3) i.oi, 
(4) 0.62, (5) 0.57, showing a considerable increase in 
several instances. 

According to Halliburton, the urea percentage of 
normal blood lies between 0.02 and 0.04, whereas in 
four of Carter's cases the analyses gave (i) 0.063, (2) 
0-057. (3) 0.05 and 0.037 respectively. 

The temperature of the body is elevated in almost 
all the unconscious cases, and fever lasts from one day 
to a week or more, the average duration being about 
three days. The temperature does not afford a 
definite index of the severity of the case, for there 
may be a low temperature with coma, as in Case 6, 
in which the temperature did not rise above 100° F., 
although the patient remained unconscious four 
hours after being brought to the hospital, or there 
may be a high temperature with normal conscious- 
ness. 

In eight cases there was a preliminary fall before 



July 9, 1904] 



MEDICAL RECORD. 



43 



the rise of temperatvire, as shown in the following 
group : 

Case 6.— The admission temperature was 97° F., 
but the pulse was 120 and respiration 28. Sub- 
sequently the temperature rose to ioo°F., with the 
same rate of pulse and respiration. 

Case 8, in which the patient's admission record 
was temperature, 96.4°F.; pulse, 126; respiration, 30. 
In this case the maximum temperature, ioi.5°F., 
was attained on the second day, but the pulse rate 
fell to 84, and the respiration to 20. Unconscious- 
ness lasted one hour after admission. 

In Case 9, although deep coma lasted for ten 
hours, the admission record was, temperature, 99°F.; 
pulse, 1 50; respiration, 30, and the maximum temper- 
ature, attained on the evening of the first day, was 
100. 2°F. 

Case 18. — The admission temperature was 96. 5° F., 
pulse, 92; respiration, 26. Within six hours the 
temperature rose to 101.5° F.; pulse, 140; respira- 
tion, 40; and the next morning the temperature 
became subnormal. 

Case 25 was that of an infant of four months. 
The child's nurse was playing with it when she 
discovered a strong odor of gas and fell unconscious; 
she soon recovered, but the infant continued un- 
conscious for about half a da}-. The temperature 
remained at 98° F., but the leucocyte count was 
52,000, somewhat above the normal for an infant. 
Recovery was prompt. 

In Case 50 the admission temperature was 96.5°, 
and within twenty-four hours it rose to 102.8" F. 
After convalescence from the gas poisoning, neuritis 
and erysipelas developed. 

Case 58. — The admission temperature was 95° F. : 
pulse, 98; respiration, 28. During the day, and 
following phlebotomy and infusion, the temperature 
rose rapidly to 102° F. with the same rate of pulse 
and respiration. The temperature continued to rise 
for five days when just before death it reached 107° F. 
The patient had been exposed all night to the gas, 
and remained comatose throughout. 

C.\SE 60. — The admission temperature was only 
96° F., although the respirations were 40 and the 
patient remained five hours in coma before death. 
Possibly subnormal initial temperature would be 
more often found except for the fact that most 
patients have been unconscious for several hours 
before discovery. The character of the tempera- 
ture varies so much that it is difficult to construct a 
typical curve. Thus the maximum, usually attained 
on the first day, may be postponed for one or two 
days, and a day of normal temperature may in- 
tervene between two febrile days. Usually the 
temperature is remittent and the subsidence is by 
lysis, and in about one-third of the cases, during 
convalescence, it becomes subnormal, often falling 
as low as 97° or 96° F. In Case 1 5 the temperature, 
after reaching 96° F., remained for five days at 97° F. 
Case 56. — Illustrates two causes of modification 
in temperature which may affect the ordinary toxic 
fever of gas-poisoning, namely infusion and pneu- 
monia. The patient was admitted with a temper- 
ature of 101.8 F., pulse 120. respiration 48. After 
a phlebotomy of 8 ozs., and infusion of 1,000 c.c, the 
temperature rose to 105.5 F., without alteration 
in the rate of pulse or respiration. A chill accom- 
panied this elevation of temperature. The latter 
fell very rapidly 6.5° F., so that the next morning 
the record was 99° F. with pulse and respiration 
unchanged. The second day the temperature rose 
again to 105° F. and the patient died on the fifth day 
of pneumonia. 

C.\SE 19. — This patient, an ignorant foreigner, 
blew out the gas on retiring, being unfamiliar with 



its effects. He had one of the most protracted 
fevers of any of the uncomplicated cases recorded 
in this series: for nine days the temperature ranged 
between 100° and 102° F., for four days more it 
reached 100°, and then for two days remained sub- 
normal, falling to 97° F. On the first day, a tem- 
perature of 102° F., which would have been ap- 
parently the limit of toxaemia temperature, was 
interrupted by the chill and elevation of temperature 
to 108° F., following phlebotomy (8 ozs.) and 
infusion (1,000 c.c). The corresponding pulse 
was 160, and respiration 56, and leucocytosis 24,300. 
Recovery. 

The vagaries of temperature are, I think, ex- 
plainable on the ground of disturbance in the 
normal chemical processes of the body, and cir- 
culatory unbalance consequent upon the altered 
pulse and respiration, rather than by the assump- 
tion of any specific thermogenetic action of the 
gas. Other gases and vapors inhaled, like the 
anaesthetics, do not produce fever, nor do chemical 
poisons as a general rule, unless they give rise to 
inflammation, although there are some exceptions 
to the latter statement, as. for example, the case of a 
child of two years who was admitted to the hospital 
within half an hour after accidentally drinking 
kerosene. The admission record in this case was: 
temperature 102.5° F-. pulse 160, respiration 60. 
The following day the temperature was 103° F. and 
the patient was drowsy and feeble, but finally 
recovered. 

The maximum temperature recorded in any of 
this series (excepting Case 19) was lo;*" F., and 
this case terminated fatally. The maximum record 
in any non-fatal case (excepting Case 19) was 
104.8° F. (Case 42). The maximum duration of 
elevated temperature in any non-complicated case 
was twenty-two days. 

An interesting case with hyperpyrexia is reported 
by William A. Steel of Philadelphia (Philadelphia 
Medical Journal, February 16, 1901). The patient 
was a girl eight years of age. The temperature rose 
rapidly after coma began, and within eight hours 
reached 110° F. with heart-beats of 215, the pulse 
being imperceptible. After the use of oxj^gen, 
hypodermoclysis, a cold plunge and vigorous hypo- 
dermic stimulation, the child recovered and was 
discharged cured from the hospital on the fifth 
day. ijg 

The pulse is markedly accelerated, and usually 
out of all proportion to the temperature and respira- 
tion. It is seldom below 120 nd frequently reaches 
136 or 140 during the coma. For example, in Case 
24 the pulse rate was 150 while the respiration rate 
was 30 and the temperature only 100.2° F. during 
coma. The pulse is usually, but not invariably, 
much weakened, but remains regular in rhythm. 
In other words, the pulse conveys the impression 
that the heart is being irritated directly or through 
its nerves by some specific form of poison. The 
acceleration is certainly not secondary to any 
changes in the lungs, for it is observed in many 
cases in which the physical examination of the 
lungs is entirely negative, as in Case 11. with a pulse 
of 142, nor is it due exclusively to the deprivation 
of the blood of oxygen, as it exceeds in degree what 
would be expected under those circumstances. 

The maximum pulse rate observed in any of the 
non-fatal cases among adults was 150. 

The respiration is accelerated irrespective of the 
condition of the lungs. It averages about 30 but 
I have records of 12 cases in which it reached 36 or 
more, although physical examination of the lungs 
was entirely negative. It is apt to be labored or 
jerky in type, and with profound coma it may be- 



44 



MEDICAL RECORD. 



[July 9, 1904 



f 



come of Cheyne-Stokes irregularity. This type of 
dyspnoea occurring independently of pulmonary 
oedema or congestion is necessarily of central 
origin, due either to the lack of oxygen at the 
medullary center or probably to the direct toxic 
irritation there of CO or some other ingredient of 
the illuminating gas. 

The maximum rate of respiration observed in 
any non-fatal case of the series was 62, although it 
reached 80 in a fatal case. 

In not a few cases artificial respiration was main- 
tained for a long time with the effect of prolong- 
ing life to recovery. In the two following cases the 
respiration rate was extremely slow for some time 
after admission: 

Case 27. — The patient, designing suicide, took the 
tube of a gas stove in her mouth and inhaled the gas 
for ten minutes. She was found pulseless, with 
respirations of only five per minute. Artificial 
respiration was performed, and hypodermic stimu- 
lation was given; she became conscious in fifteen 
minutes and recovered without fever, although the 
pulse reached 120. 

"In Case 42 the respiration on admission was only 
two or three per minute, and artificial respiration 
was maintained for an hour. Phlebotomy and in- 
fusion were performed and the breathing improved, 
the rate rising to 32. (Recovery.) 

Digestive disturbances are observed but are not 
severe or characteristic. Constipation is the rule, 
and vomiting sometimes occurs, more often in the 
mild cases or during convalescence from coma; it 
became severe in eight cases of the series. 

Extreme dryness of the mouth, and congestion, 
redness, and dryness of the pharynx were observed 
in many cases. 

Several patients experienced excessive perspira- 
tion. 

The urine presents no special peculiarities. It is 
often of high specific gravity, 1,025-1,032, and the 
proteid waste is usually somewhat increased. A 
heavy deposit of uric acid is common. Albuminuria 
was noted in twenty-six cases of the series. In 
many the albumin was represented by a mere trace, 
in others there was 10 per cent, by volume, with 
hyaline and granular casts. As many of these cases 
occurred among the alcoholic or those of advanced 
years, it is probable that the gas has no direct 
influence in producing albuminuria, although it was 
observed in an infant of four months. 

Casb 55. — In this fatal case, metheemoglobin was 
found in the urine on the first day and again on the 
third. In several other cases in which it was 
searched for, it was not present. 

In many cases there was retention of urine 
and catheterization was often necessary, even after 
consciousness was regained. In the majority of 
cases constipation was obstinate, and repeated doses 
of cathartics and enemata were reqxiired. In eight 
cases there was incontinence of both urine and 
faeces, in some instances persisting three or four 
days, and outlasting the stage of coma by two or 
three days. In a few more cases there was incon- 
tinence of urine alone. 

The pupils present such varied appearances that 
there is nothing typical about them. In fully one- 
fourth of the cases they appeared normal and re- 
acted normally. In twelve cases they were dis- 
tinctly enlarged, sometimes with, sometimes without 
reaction to light. In a half dozen cases they were 
diminished, twice they were vtnequal in size, and in 
two cases there was temporary nystagmus, one pre- 
senting also lateral deviation of the eyeballs. 

In one or two cases a sensation of fulness and 



ringing in the ears was complained of, and in one 
instance deafness persisted for a day in one ear. 

As stated above, the nerve symptoms are so varied 
as to force the conclusion that illuminating gas acts 
as a direct poison to the central nervous system, 
for they cannot all be accounted for upon the theory 
that the gas acts alone by depriving the red blood 
corpuscles of their ability to transport oxygen. 
These symptoms are: tremors, muscular twitching, 
convulsions, rigidity, opisthotonos, anaesthesia, in- 
creased reflexes, headache, and coma. 

The nerve symptoms vary with the mode of 
poisoning. When the patient is awake, and inhales 
the gas slowly or well diluted, he experiences head- 
ache and vertigo, often accompanied by nausea and 
vomiting with muscular prostration. Evidence of 
vasomotor paralysis appears in burning sensation 
in the skin, especially of the face, and in redness of 
the cutaneous surface. Later the lips and extrem- 
ities become bluish, although, owing to the peculiar 
cherry-red color imparted to the blood by CO, the 
ordinary duskiness of extreme cyanosis for some 
time may remain absent. It is important to note 
that the degree of cyanosis is independent of any 
changes in the lungs, such as congestion, oedema, 
etc., and is often extreme, while the lungs remain 
normal. 

The patient meanwhile experiences visual dis- 
turbances, confusion of ideas, and becomes drowsy, 
perhaps delirious, anaesthetic, and finally comatose. 

In cases in which the patient is poisoned while 
asleep or under the influence of alcohol, or in cases 
in which a large quantity of the concentrated gas is 
at once inhaled, the preliminary nervous phenomena 
above mentioned are absent, and the patient passes 
at once into coma without wakening. The coma, 
which is always profound, is usually accompanied by 
loud stertorous breathing, and sometimes by dilated 
pupils, and involuntary evacuation of faeces and 
urine. In some cases, after hours of unconscious- 
ness, the patient may be partially aroused to take 
nourishment only to relapse again. The coma may 
last from half an hour to many days, and it is usually 
accompanied, as stated above, by elevation of body 
temperature and a rapid feeble pulse, but there are 
afebrile cases of coma, as there are cases in which it 
is the chief and almost the only symptom. In 
Hewetson's case the coma lasted nine days and was 
fatal. In Case 46 it lasted ten days. 

As the patient slowly regains consciousness, he 
may suffer for 'days from mental weakness, dulness, 
and confusion with loss of memorj'. Paresis or 
spasm of the extremities may persist for several 
days after coma with muscular weakness, but in the 
majority of cases complete recovery is fairly prompt 
without sequelae. 

A large number of cases have been reported in 
recent years in which there were interesting sj^mp- 
toms referable to the brain, cord and peripheral 
nerves, symptoms which can be well explained after a 
review of the reported autopsies which follow (p. 45) : 

Bruneau' reported a case of hemepligia following 
gas poisoning. Frinkelstein," one of dementia , and A. 
Scott,' one of acute mania with recover^', after ten 
days. Zeiler' reported a case of leptomeningitis 
serosa. Bruns' reported a case of disseminated 
encephalomyelitis, and Alexander Panski,'" another 
in which the patient was ill for months with paralysis 
of the legs and arms, sensory and speech disturb- 
ances, anasmia and mental weakness. Becker" re- 
ported a case with multiple sclerosis. Cases with 
multiple neuritis have been reported by Glynn," 
Meczkowski" (three cases), Sko-nTOuski," Brugman 
and Gruzewski" (six cases), and others. 



July 9, 1904] 



MEDICAL RECORD. 



45 



The only occasional sequelae apart from those 
above described referable to the nervous system, are 
bronchitis, bronchopneumonia, and lobar pneumo- 
nia. Small mentions diabetes as a possible sequel ; 
it was not noted in any of the cases of my series. 
Pleurisy was observed once. Tuberculous patients 
did not appear to suffer more than those with 
normal lungs. 

The assertion is made by Small (XX Century Prac- 
tice of Medicine, Vol. Ill, p. 589) that the chance of 
recovery lessens with the duration of exposure to the 
gas, and that after eight hours of coma there is very 
little chance of recovery, j-et this is by no means an 
infallible rule — for example, Hewetson reported, in 
the Johns Hopkins Hospital Bulletin for 1893, the 
case of a man who was exposed for the very brief 
period of three minutes to the inhalation of gas in 
an open trench. On immediate removal he was 
insensible; coma with repeated convulsions lasted 
for nine days when the man died. This case is also 
opposed to another assertion of Small (loc. cit., p. 
588) that when the onset of coma is sudden, it is 
less likely to be either profound or prolonged. It 
does not appear from my cases that the mode of 
onset of coma is of much prognostic significance. 
The following cases are cited in illustration; 

C.\SE 3. — Male. German, forty-five years old; 
became despondent through loss of work and, having 
complained all day of headache, put an open gas 
pipe in his mouth, and was found unconscious a few 
minutes after, by his wife. In the hospital he 
exhibited profound coma, a feeble, irregular pulse, 
and a chest full of large sonorous moist rales. 
Respiration was of Cheyne-Stokes type, and the 
exhaled breath smelled strongly of gas for twelve 
hours. The eTacuations of urine and faces were 
involuntary. The chest was cupped, phlebotomy 
was performed ( 3 viii) followed hy infusion (c.c. 
1. 000). Slight improvement resulted, but profound 
coma persisted for four days, when the patient could 
be aroused to take nourishment. His maximum 
temperature was only 100.5"; pulse, 104; respira- 
tion, 24, and leucocytes, 10,400. On the eleventh 
day the patient was discharged cured, although the 
persistence of melancholia should remind one that in 
suicidal cases, melancholia during convalescence 
might be mistaken for a remaining symptom of 
poisoning. 

This case is interesting on the following grounds: 
(a) The sudden onset of profound coma; (6) the 
predominance of coma over all other symptoms, 
notably the nearly normal pulse, respiration, and 
temperature ; (c) the final recovery after four days of 
deep coma. 

C.\SEs 43, 44, 45, and 46 belonged to a series of 
five patients all sleeping in one room into which 
water-gas, containing 20 per cent, of carbon monoxid. 
escaped for about ten hours. All were equally 
exposed: one died after eight days, two recovered in 
four and five days respectively, and one remained 
either comatose or delirious and stupid for three 
weeks, with a continued fever, but without pneu- 
monia; he was finally taken home, when nearly 
well. (The fifth patient was not brought to the 
hospital.) 

E. H. Hartley states (Wood's "Reference Hand- 
book of the Medical Sciences," Vol. II, p. 215) that 
" when entire unconsciousness has occurred recovery- 
is very unusual." This is, to say the least, a pes- 
simistic view, for of the 90 cases of this series in 
which coma was profound 73 resulted in recovery. 
In 39, or more than one-half of the non-fatal cases, 
coma lasted one day or longer, and in 12 more it 
lasted half a day (12 hours). Among the longest 
non-fatal coma records are the following: i case of 



10 days' duration, i of 4 days; 4 of 3 days, and 4 of 2 
days. 

Rigors may be present, but more common are 
general muscular tremors and twitching or spasm, 
which latter may finally result in violent con- 
vulsive seizures and opisthotonos. Repeated con- 
vulsions have been known to last for days. In 
Hewetson's case they persisted for nine days; 
in some of my cases for three or four days. In 
eight cases they were very severe. One patient 
had convulsions on the third day for the first 
time, but she gave a history of epilepsy, and 
they were apparently of that origin. She recovered. 

Rigidity of a part, or of all of the skeletal muscles, 
was_,very persistent in a half dozen cases, and in one 
it lasted in some degree for three weeks, and was 
often accompanied by twitching or convulsions. 
(Recovery). The major reflexes present consider- 
able variation. In many cases they were normal, 
and when altered, in about equal number they 
were increased or diminished. During conval- 
escence patients often complain of stiffness of the 
muscles and sometimes appear dazed when first 
attempting to walk. 

A patient of Broadbent's (British Medical Journal. 
May 13, 1903) improved for ten days, when rapid 
muscular atrophy ensued, and the asthenia cul- 
minated in death on the nineteenth day. 

Phlebotomy, followed by venous infusion of 
normal salt solution, should be performed in every 
case in which the patient is unconscious and the 
pulse is vigorous. Infusion alone should be per- 
formed in every unconscious case in which the 
pulse is too feeble to justify phlebotomy. If these 
operations are done at all they should be thorough. 
It is better to withdraw 15 or 18 ounces of blood 
than 8 or 10 whenever the pulse strength permits, 
and at least 1500 c.c. of saline solution should be in- 
fused. The latter process may be repeated upon 
the opposite arm, or hypodermoclysis and saline 
enemata ma}^ be given. The objection some- 
times raised against saline infusion, that it may 
produce pulmonary oedema, is not sustained by 
the evidence of the series of 41 cases in which it was 
employed, for in no one of them did it give rise to 
the physical signs or the post-mortem finding of 
cedema of the lungs, but, on the contrary, often 
relieved this condition when already present. 
Whether the phlebotomy and infusion act by 
removing a small portion of the poison, by diluting 
the blood, affecting the vascular pressure, by the 
influence of the salt infused, by stimulating the 
formation of new red blood cells, or in some other 
manner, the clinical fact remains that these 
measures are beneficial. They do not immediately 
restore consciousness, but in the bedside notes 
of the cases herein reported it is almost invariably 
stated that immediately after infusion the pulse 
grew stronger, respiration was of better character, 
muscular twitching disappeared, rigidity lessened, 
and the general condition of the patient improved. 
Of course there are many cases in which a very large 
dose of the gas renders all curative efforts futile, but 
in a considerable proportion the improvement which 
follows phlebotomy and infusion ultimately results 
in recovery. 

Pathological Findings. — In the succeeding twelve 
cases, in which autopsies were performed, I shall 
merely quote the records in so far as they concern 
the heart, lungs, and brain, as nothing distinctive 
was observed in the kidneys or any other organs. 
For these records I am indebted to the pathologists 
of the Presb\i:erian Hospital, and (for one case) to 
Dr. W. J. Elser. 

C.\sE 54. — Heart muscle pale and flabby; left 



46 



MEDICAL RECORD. 



[July 9, 1904 



pleura adherent-to thorax throughout ; lungs on sec- 
tion both show congestion and oedema throughout; 
brain appears normal. 

Case 86. — Heart presents lesions of chronic endo- 
carditis and myocarditis; the mitral valve is irreg- 
ularly thickened, and there are numerous calcareous 
vegetations on the aortic valve; lungs pale but 
otherwise normal; brain, a calcareous embolus is 
found lodged in the internal carotid artery, at the 
origin of the middle and anterior cerebral arteries. 
The lodgpnent of this embolus explains an attack of 
partial hagmiplegia which the patient had three 
months before death, and did not appear to be in 
any manner connected with the cause of death; the 
brain otherwise appeared normal. 

C.vsE 78. — Heart presents fibrous patches on the 
endocardium and fatty degeneration of the papillary 
muscles; lungs, the right lower lobe of the lung is 
congested and the left lung is oedematous anteriorly; 
areas of bronchopneumonia involve the right upper 
lobe and posterior part of the left lower lobe; the 
brain exhibits atheromatous nodules in the left 
middle cerebral arterj', and congestion of the vessels 
of the pia, corpus callosum'and corpus striatum. 

Case 80. — Heart soft and .flabby, but not dilated, 
filled with fluid and clotted blood; lungs are both 
slightly oedematous, otherwise normal; brain, evi- 
dence of chronic meningitis is present; the dura 
mater is adherent to the calvareum, and both 
meninges and brain substance are much congested; 
the lateral ventricles contain a small quantity of 
bloody serum. 

Case 55. — Heart normal; lungs: left pleura pre- 
sents patches of fibrous thickening near the base of 
the lung, and a few petechias over the posterior part 
of the left upper lobe, the latter is oedematous and 
congested; the left lower lobe is dark red and its 
posterior portion is atelectatic; the right pleura is 
here and there adherent, the right lung is empha- 
sematous anteriorly, but posteriorly it is congested 
and oedematous, with areas of partial atelectasis; 
the brain substance, arachnoid and pia are all mod 
erately congested. 

C.\sE 56. — Heart muscle and pericardium are of a 
dark reddish or purple hue; the heart is otherwise 
normal; lungs: the left upper lobe of the lung is 
tuberculous, the left lower lobe is congested; the 
right lung shows areas of emphysema, congestion 
and bronchopneumonia; the brain substance and 
arachnoid are congested. 

Case 57. — Heart normal, excepting slight 
atheroma of the coronary arteries; lungs: the entire 
pleura is everywhere adherent, and the left upper 
lobe of the lung presents a chronic miliarv tuber- 
culosis; miliary tubercles are also scattered through- 
out the right lung; congestion and oedema are 
absent; brain not examined. 

Case 58. — Heart muscle flabby, but the organ is 
otherwise normal; the right pleura is somewhat 
adherent, the bmgs are normal ; brain not examined. 
Case 59. — Heart normal; pericardium dry, but 
non-adherent; lungs: few petechias on entire pleura; 
posterior portion of left upper lobe of the lung is 
dark and somewhat atelectatic, right upper lobe is 
congested posteriorly, emphysematous anteriorly, 
right lower lobe somewhat atelectatic posteriorly; 
trachea and larynx are deeply congested; the brain 
is much congested throughout. 

Case 85. — The heart muscle is pale and flabby, the 
left ventricle is slightly dilated; the lungs are both 
deeply congested, and show slight emphysema 
anteriorly; the pleura is adherent over the right 
upper lobe; brain not examined. 

Case 60. — Heart shows advanced stage of chronic 
endocarditis with calcareous deposit in and vegeta- 



tions upon the aortic cusps, a thickened mitral valve 
and retracted chordae tendineae; the heart muscle 
is pale and hypertrophied ; the lungs are congested 
and oedematous and the pleura is adherent over the 
right upper lobe ; the brain tissue appears normal 
but the cerebral vessels are highly atheromatous. 

Case 61. The heart is slightly hypertrophied and 
filled with partially clotted dark red blood. The 
myocardium is of a pale red, somewhat cloudy ap- 
pearance; in the coronary vessels and aortic arch 
is a moderate grade of atheroma; the valves are 
normal. The lungs present a moderate grade of 
congestion and oedema, and in the lower lobes are 
foci of aspiration pneumonia; the bronchi are con- 
gested and contain an abundant serous exudate; 
in the pleurae on both sides are about 100 c.c. of 
clear serous fluid. The brain substance is soft and 
oedematous, the convolutions are flattened and the 
meninges congested; the ventricles contain much 
fluid; the anterior internal portion of the left ven- 
tricular nucleus, and the adjoining portion of the 
internal capsule exhibit an area of softeningabout 
three-quarters of an inch in diameter, which con- 
tains a number of minute capillary hemorrhages; 
the basilar vessels are normal. 

[The notes of this autopsy were furnished by Dr. 
William J. Esler, from the clinic of Dr. G. L. Pea- 
body, at the New York Hospital.] 

It is of some interest to note that in no one of these 
twelve fatal cases was there entire absence of some 
serious chronic lesion in heart, lungs, or brain, 
despite the fact that many of the patients were 
young. Thus chronic endocarditis, myocarditis, 
tuberculosis, pleuritic adhesions, atheroma, chronic 
meningitis, etc., testify to the ill health and lowered 
vitality of a class of patients whom privation and 
physical suffering may have driven to suicide, or 
whom ignorance, stupidity, or alcoholism has led to 
fatal poisoning. The important conclusion seems 
justified that many of these patients might have 
survived the gas intoxication, had not either their 
respirator}^ circulatory, or nervous mechanisms been 
already seriously undermined. 

The Heart. — Among the twelve autopsies, in three 
the heart was normal, in three it is described as 
"pale and flabby," and in six there was evidence of 
either chronic endocarditis, myocarditis, or atheroma 
of the coronary vessels. Hence there is no constant 
appearance of the heart in gas poisoning. If this 
toxic agent caused death bj' direct paralysis of the 
heart, it might be expected to be uniformly pale 
and flabby and perhaps dilated, but the few cases in 
which these occurrences were noted arc offset by 
others in which it appeared normal, or (as in Case 
56) of a dark red color. 

The Lungs. — It was a surprise to the writer that 
bronchopneumonia, or other definite pulmonary 
lesion, is not more eonstantly an outcome of fatal gas 
poisoning, but in only three of the twelve autopsies 
was bronchopneumonia observed. I have seen it in 
one other private case in which it followed complete 
recovery from the gas intoxication and ultimately 
proved fatal. Two other cases of this series pre- 
sented normal lungs, and a third, lungs which were 
without congestion or oedema, having only a few 
miliary tubercles, hence it maj' be asserted that 
death from illuminating gas is not invariably due, if 
it ever is. to direct irritant action upon the lungs or 
bronchi after the manner of smoke or toxic vapors. 
The conditions which might be attributed to such 
action may be described as functional disturbances 
rather than organic changes, such are: (i) Conges- 
tion, complete (one case); (2) congestion and 
oedema, complete (three cases); congestion and 



July 9, 1904] 



MEDICAL RECORD. 



47 



cedema in partial areas (five cases), in all eight cases; 
(3) atelectasis, partial (two cases); (4) emphysema, 
compensatory and partial (four cases). These four 
different conditions were found in varying degree 
and association in nine of the twelve cases examined, 
yet it is well known that all these appearances are 
common in the lungs of those dying slowly from 
profound toxic influences affecting the blood, the 
circulation or the central nervous system, without 
reference to any specific pulmonary irritation what- 
ever, and such would appear to be the fact in il- 
luminating gas poisoning. 

The Brain. — Of the nine cases in which the brain 
was examined, six presented marked congestion of 
the brain substance, pia and arachnoid; in one of 
these cases, however, there was evidence of a chronic 
meningitis; in the three remaining cases the brain 
and its membranes seemed normal. It would thus 
appear that cerebral congestion is a common result 
of poisoning from illuminating gas, occurring in the 
series of autopsies cited, six times out of nine. To 
what extent this may be a cause of death is difficult 
to determine, but there can be little doubt that it is 
often a contributing factor, although not invariably 
present. In three of the cases there were marked 
changes in the corpus callosum, corpus striatum or 
ventricles, consisting of such conditions as softening, 
congestion, and hemorrhages. 

These appearances, which have also been reported 
by other writers, are of the greatest interest. Some 
years ago Klebs pointed out the fact that carbonic 
oxide poisoning is capable of producing enormous 
distention of the cerebral arteries, and in 1893 
Alexander Kolisko" referred to this distention of the 
central terminal branches of the anterior cerebral 
artery as the seat of thrombosis following distention, 
and giving rise to the softening of the internal 
capsule, and especially of the lenticular nucleus, 
which has been often observed. He states that he 
has seen several such cases resulting from CO 
poisoning, and refers to two more observed by 
Polcher. Another interesting case of softening of 
the internal capsule and lenticular nucleus was re- 
ported by Broadbent," also in 1893. Schaeffer" has 
reported two fatal cases in which he found softening 
of the brain, cord, and peripheral nerves. 

Von Solder" reported the case of a man, forty-one 
years of age, who died four months after gas inhala- 
tion. At autopsy were found hyaline and fatty 
degeneration of the skeletal muscles, atrophy of 
peripheral nerves, and degeneration of the anterior 
horns in the cervical and dorsal cord. J. W. 
Runeberg'" reported two fatal cases with extensive 
softening in the lenticular nucleus. 

Summary. — From a study of the foregoing 'cases 
the following conclusions regarding comatose cases 
of illuminating gas poisoning may be drawn: 

1. Leucocytosis is both high and persistent, rising 
in many cases above 18,000, and in a few fatal cases 
as high as 50,000. A differential leucocyte count 
shows preponderance of the polymorphonuclear 
cells. A high degree of leucocytosis is a very un- 
favorable prognostic symptom. 

2. Elevation of temperature is observed in nearly 
all cases. The fever is usually moderate and of very 
irregular type. In many cases a subnormal temper- 
ature precedes the elevation, and it is often observed 
also in convalescence. The pulse is disproportion- 
ately rapid, as compared with the temperature. 

3. The nervous symptoms are both varied and 
inconstant. Convulsions occur in about 7 per cent, 
of all cases and muscular rigidity in a slightly larger 
proportion. The reflexes and pupil symptoms show 
great variability. The coma bears no definite re- 
lation to the intensity or duration of the fever. 



Coma lasting four or five days is not invariably 
fatal. In the series of ninety comatose cases only 
seventeen cases, or 18.8 per cent., were fatal. 

4. The results of combined phlebotomy and saline 
infusion justify the prompt and thorough employ- 
ment of these meastires. 

5. Pneumonia is an infrequent complication, and 
in a large percentage of fatal cases the cause of 
death may be referred to cerebral lesions, such as 
congestion of the meninges and brain substance, 
hemorrhage of the cerebral capillaries, or hemor- 
rhage into and softening of the internal capsule, 
lenticular nucleus, and adjacent structures. 

REFERENCES. 

1. Die Kohlenoxydvergiftung, etc., 1900. 

2. Neurologisches Centralblatt, 1902, No. 6, S. 242.. 

3. Textbook of Chem. Physiol, and Pathol., p. 61. 

4. Loc. cit., p. 251. 

5. "Thdse," Paris, 1893. 

6. "Jahrbxich fur Psychiatrie," 1896. 

7. Lancet, 3778. 

8. "Inaugural Dissertation," 1897. 

9. "Encyklopadisches Jahrbuch der gesammte Heil- 
kunde, Bd vi, 1896. 

10. Neurologisches Centralblatt. 1902, No. 6, S. 242. 

11. Deutsche medizinische W'ochenschrijt, 1893. 

12. British Medical Journal, 1895. 

13. Gasetta Lekarska, 1899, Nos. 48 and 49. 

14. Fortschritte der Medtzin, igoi. No. 18. 

15. Kronika Lekarska, 1897, No. 4. 

16. Wiener klinische Wochenschrijt, 1893, Bd. vi., No. 
1 1, p. 192. 

17. British j\Iedical Journal. 1893, p. 1004. 

18. Deutsche medizinische Wochenschrijt, 1903, Bd. cc. 
ig. "Jahrbuch fiir Psychiatrie," 1902, Bd.xxii, p. 287. 
20. " Abhandlungen der finnlandische Gesellschaf t der 

Aerzte," Bd. xliv. 

34 E.\ST Thirty-first Street. 



THE DIAGNOSIS OF TYPHOID PERFORA- 
TION AND ITS TREATMENT BY OPERA- 
TION.* 

By CHARLES A. ELSBERG, M.D.. 

NEW YORK. 
ADJUNCT ATTENDING SURGEON TO THE MT. SINAI HOSPITAL. NEW YORK. 

It is now generally recognized that — in spite of the 
fact that an occasional patient will ecover without 
surgical interference — operative treatment is indi- 
cated in every case of perforation of the intestine in 
the course of typhoid fever as soon as the diagnosis 
has been made. The main questions that confront 
the medical man are (i) on what can we base the 
diagnosis of perforation and the indications for 
operation, and (2) in what cases are we justified in 
recommending surgical interference when the diag- 
nosis is still in doubt. Operative interference for 
suspicious symptoms is a course that has been, 
declared justifiable by most writers on this subject, 
among whom may be mentioned Finney,' Cushing," 
Herringham and Bowlby,' Shattuck, Warren and 
Cobb,' and many others. Inasmuch as the dangers 
from a small exploratory incision are much smaller 
than those of a perforation of the intestine, this 

*Read at the meeting of the Surgical Section of the 
New York Academy of Medicine. This^ paper is based- 
upon four cases of perforation of the intestine in the- 
course of typhoid fever that the writer has operated 
upon in the Second Surgical Service at Mt. Sinai 
Hospital (Dr. Howard Lilienthal, Attending Surgeon), 
and upon the occasional observation of eleven others 
which were operated upon by others of the sur- 
gical staff of the hospital during the past three years. Of 
these fifteen cases, five were operated upon in the First 
Surgical Service of Dr. A. G. Gerster during 1901 and 
1902, and have been already published in the Mt. Sinai 
Hospital Reports for those years; ten were operated upon 
in the Second Surgical Service from 1901 to 1903, The cases 
that occurred in 1901-1902 are published in the annual 
hospital reports for those years : those from the year 
1903 have not yet appeared in print, and will form part 
of a report on the surgery of the intestines in the Second 
Surgical Service of Dr. Lilienthal for the past four years, 
which will be published elsewhere. 



48 



MEDICAL RECORD. 



[July 9. 1904 



course would certainh' seem the correct one. .-Vs I 
shall mention later, however, delay is advisable in 
some of the cases. 

There has been much discussion as to what is 
meant by the term "symptoms of perforation," and 
there is still little unanimity of opinion on this 
question. The attempt to distinguish between the 
symptoms of perforation and those of the resulting 
peritonitis is in very many cases impossible. The 
only symptoms of perforation, per se, that I can 
conceive of are, perhaps, sudden abdominal pain 
and the presence of free gas in the abdominal cavity. 
Sudden abdominal pain occurs fairly often during 
the course of typhoid fever, and localized pain and 
distention of the abdomen are verj' frequent in this 
disease, as has been ably shown by McCrae.' The 
presence of free .gas in the peritoneal cavity — if it 
can be clearly demonstrated — is almost pathogno- 
monic of perforation. Unfortunately, however, it 
is often difficult, if not impossible, to determine with 
certainty that the gas in the abdominal cavity is 
free, and in the second place, in many cases of per- 
foration of the intestine there is no free gas. In the 
large majority of cases the diagnosis of perforation 
is made from the symptoms of an affection of the 
peritoneum which has been caused by the perfora- 
tion and not from any symptoms concomitant with 
and caused by the perforative process. This is the 
view now adopted by Osier.' 

By this I do not mean to say that there is 
not anj'thing characteristic in the onset, and more 
especially in the symptoms of the peritonitis, but 
that, in the large majority of instances, we are really 
describing the early symptoms of peritonitis due to 
the perforation, rather than the symptoms of the 
perforation itself. In what follows, however, the 
term symptoms of perforation will be used for the 
sake of simplicity of expression, instead of the 
longer term symptoms of peritonitis due to a per- 
foration. 

I. Some Diagnostic Features of Typhoid Perfora- 
tion. — It is always important to obtain from the 
physician in attendance data as to the amount of 
tympanites, pain, tenderness, etc., that the case 
presented during the entire course of the typhoid 
fever. We have to learn from the internist regard- 
ing the appearance and changes in the symptoms 
and signs from the beginning of the symptoms of 
perforation. In the cases on which this paper is 
based, there was usually the histor}'- of the patients 
having suddenly complained of abdominal pain, or 
of the more or less sudden appearance of signs of 
increase of the existing pain and tenderness. 
Thereafter a number of signs and symptoms ap- 
peared and progressed until the diagnosis of in- 
testinal perforation could be made with certainty. 
At this time the patients had more or less increase 
in the pulse and respiration, some were in collapse, 
others not so, the abdomen was tender, distended, 
and rigid to a varying degree, there were the signs 
of free fluid and sometimes of free gas in the peri- 
toneal cavity. Collapse does not occur as often as 
one would expect in these patients, and it would 
seem as if the degree of collapse was dependent more 
upon the virulence of the peritoneal infection than 
upon the size of the perforation or the amount of 
intestinal contents that has escaped. Thus of the 
fifteen cases that form the basis of this paper, only 
four were in collapse when the diagnosis of perfora- 
tion was considered sufficiently certain to indicate 
operative interference. In almost all of the pa- 
tients the general condition became steadily worse 
up to the time of operation, in most of them the 
condition was very poor, but only four were in utter 
collapse at the time of the laparotomy. 



The distention of the abdomen varied much in the 
fifteen cases. In six cases the distention was very 
marked, in eight the distention was only slight or 
moderate, in one case there was no distention. It is 
rare that the abdominal distention is due to the 
escape of a large quantity of gas from the perforated 
bowel. The gas is usually within the intestine, very 
often the amount of abdominal distention is directly 
proportional to the degree and extent of the peri- 
toneal inflammation. 

Diminution in the area of liver dulness has been a 
valuable diagnostic aid to us in our cases. There 
was a greater or lesser diminution in the area of liver 
dulness in fourteen of the fifteen patients. In a 
considerable number of cases this diminution is due 
more to the intestinal distention than to the presence 
of free gas in the peritoneal cavity. A distended 
transverse colon or small intestine may get in front 
of the liver or rotate it on its transverse axis, and in 
that way cause a diminution in the area of normal 
liver dulness. Hence the value of attempting to 
percuss out the colon very carefully and of knowing 
when the patient's bowels have last moved and what 
amount of flatus was passed at that time. 

Abdominal pain and tenderness are usually most 
marked on the right side of the abdomen, although 
the entire abdomen is often tender in these patients. 
In six cases of those on which this paper is based, 
all parts of the abdomen were equally tender; in 
seven the tenderness was most marked on the right 
side and lower part of the abdomen ; in two cases the 
greatest amount of tenderness was in the left iliac 
region. 

In sixteen patients there were the signs of free 
fluid in the abdomen — movable dulness in the flanks 
or fluid wave or both. 

Although the normal area of liver dulness was 
considerably diminished in fourteen patients, as has 
been already mentioned, free gas could be demon- 
strated in only five of these. The presence of mov- 
able tympany in the flanks with concomitant changes 
in the area of liver dulness is characteristic of free 
gas in the abdominal cavity. The patients are 
usually examined for the evidences of free gas by 
turning them first on one side and then on the other 
and percussing both flanks in these positions. It 
is advisable to move these patients as little as pos- 
sible, however, and a verj- thorough examination for 
free gas is therefore often not made. I have found 
it a very useful and valuable expedient, when exam- 
ining for free gas, to have the headend of the patient's 
bed raised up very high by an orderly and then to 
percuss the upper and lower parts of the abdomen 
very carefully ; then to have the head end of the bed 
lowered and the foot end raised and then to percuss 
the abdomen again, and to observe the changes that 
have taken place. I have found the method a very 
useful one for the demonstration of free gas in the 
peritoneal cavity, without moving the patient from 
his dorsal position. 

The temperature changes in the cases did not seem 
to present anything characteristic, the temperature 
was sometimes high and at other times low when the 
first symptoms referable to the peritoneum were 
noted. 

In about one-half of the cases there was a leuco- 
cytosis of between 11.000 and iS.ooo. in the other 
patients there were less than 8.000 white cells to the 
cubic millimeter. Regarding the value of leuco- 
cytosis.we have come to the same conclusion as many 
other recent writers — that the leucocytosis has but a 
limited value. The presence of a leucocytosis can 
be used only with circumspection as a diagnostic 
symptom, while its absence does not at all exclude 
the possibility of a perforation. 



July 9, 1904] 



MEDICAL RECORD. 



49 



II. The Indications for Operative hitcrfcrevce. — 
In most of the cases referred to in this paper, the 
diagnosis of perforation of the bowel could be made 
with almost certainty within four to twelve hours 
from the appearance of the first suspicious symptom. 
As most of the patients were transferred to the 
surgical side of the hospital from the medical side, 
the surgeon was asked to see the cases at a very early 
stage, but there was often considerable delay before 
permission for the surgical interference could be 
obtained. The diagnosis was usually first made by 
the house staff of the hospital, who were on the spot 
to watch the symptoms from their beginning, and 
much credit should be given these gentlemen for the 
care with which they studied the cases. During the 
past three years not a single patient has been oper- 
ated upon at our hospital for typhoid perforation in 
which the perforation was not present. One case in 
which all the symptoms and signs which are con- 
sidered characteristic of perforation were present, and 
in which permission for the operation was refused, 
recovered without operative interference ; two pa- 
tients died without operative interference, as in 
both the condition was so bad that surgical inter- 
ference of anj' kind was considered contraindicated. 
If perforation of the bowel in the course of typhoid 
fever is considered a surgical complication — and 
there is very little doubt that it should be consid- 
ered so — then immediate surgical interference should 
follow as soon as the diagnosis has been made. 
These patients bear the operative interference re- 
markably well if only the manipulations are rapidly 
done; and one is soon convinced of the correctness 
of the statement made by Gushing' that the "diag- 
nosis once having been made, nothing short of a 
moribund condition of the patient is a contraindica- 
tion to immediate operation." 

In the cases in which the diagnosis is probable, 
especialljr if the general condition of the patient is 
becoming steadily worse, it is advisable to make a 
small exploratory incision. The operation can be 
completed in less than ten minutes, and, if the peri- 
toneal cavity should be found normal, the abdomen 
can be quickly closed again, and the patient be sent 
back to his bed with a good expectation that his 
general condition will be little or not at all made 
worse by the operation. 

It is more difficult, however, to determine if an 
operation should be done when the symptoms make 
one suspicious that a perforation may have taken 
place, but the symptoms are not clear. Of these 
cases, a number really have a perforation, and in 
them a policy of delay would not be the one in the 
best interests of the patient. From our experience 
with typhoid perforation during the last three years 
we have been forced to conclude that when the 
symptoms have been of at least twelve hours' dura- 
tion and the signs and symptoms point more to a 
perforation than to anything else, especially if the 
patient's general condition is growing steadily worse, 
the operation is a justifiable one. 

It need hardly be mentioned that if the signs of 
peritonitis are sufficiently marked to indicate op- 
erative interference, no matter what the diagnosis, 
delay would be inexcusable. 

If, however, the symptoms have existed for more 
than twenty-foiir hours, the patient's general con- 
dition has remained good, and the diagnosis is still 
in doubt, perhaps because the patient has only come 
under observation at this time, the surgeon is justi- 
fied in advising a few hours' delay if the case can be 
carefully watched. If a case of this kind has a per- 
foration, it is probable that the affected loop of 
intestine is walled off bj' adhesions from the general 
peritoneal cavitv. Delay in these late cases should, 



however, only be advised after the most careful con- 
sideration of the case from every aspect. If the 
diagnosis is fairly sure, it would be just as wrong to 
wait for adhesions to form in these cases as in a case 
of acute appendicitis. The danger of an ill-timed 
delay is very great, and it is better to open an 
abdomen in rare instances and to find nothing than 
to delay too long where early operation is called 
for. With thorough observation and careful in- 
dividualization it is probable that mistakes on one 
side or the other will be very few. 

About six weeks ago a patient was admitted into 
the hospital with symptoms of more than twenty- 
four hours' standing of perforation of the intestine 
in the course of typhoid fever, in which Dr. Lilien- 
thal advised delay on account of the good general 
condition of the patient, the duration of the symp- 
toms, and the lack of certainty of the diagnosis. 
Twenty-four hours later, however, the signs of peri- 
tonitis became more marked, immediate operation 
was done, and a large, well-walled-off abscess 
opened. A fecal fistula became established, but 
closed after several weeks, and the patient is now 
convalescent. 

II. Some of the Conditions Found at Operation. — 
In ten of the fifteen cases the abdomen contained 
seropurulent fluid in considerable quantities, and 
there were no adhesions between the coils of in- 
testine or, at the most, only a few flakes of fibrin 
on the intestines. In all of these cases the operation 
was done in less than twenty hours from the be- 
ginning of the symptoms of perforation. In five 
patients there were adhesions in considerable num- 
ber between the coils of gut and the omentum, and 
in these cases the perforated loop of intestine was 
usually walled off by the adhesions from the re- 
mainder of the peritoneal cavity, and there was a 
collection of seropurulent fluid or pus in this walled- 
off cavity. In these five cases the length of time 
between the beginning of the symptoms of perfora- 
tion and the operation was 36, 18, 24, 6, and 48 
hours, respectively. The foregoing figures show 
that adhesions are not verj' frequent in the early 
stages of typhoid perforation. Whether this want 
of the tendency to form adhesions is due to the low 
percentage of the fibrin factors in the blood serum 
of these patients, or to something in the intestinal 
contents (toxin? typhoid bacillus?) which has an 
influence in preventing the formation of adhesions, 
it is impossible to say. Many authors have men- 
tioned the fact that adhesions are rare in the early 
stages of perforative peritonitis in typhoid fever 
without attempting to give any -explanation for it. 
(Gushing,' McCrae and Mitchell,' Russel,' Fix and 
Gaillard," etc.) Sometimes the perforation is 
closed by fibrin, or by an adhesion of omentum or 
neighboring coil of intestine, but more often it opens 
free into the peritoneal cavity, so that when the 
perforation is exposed, fecal material is to be seen 
to be escaping from it. 

In six of the fifteen cases the abdominal cavity 
contained free gas, in five of which the free gas was 
demonstrable before the operation. As has been 
already mentioned, the presence of free gas in the 
peritoneal cavity makes the diagnosis certain. 

Deep ulcerated Peyer's patches, which have not 
yet perforated, can be plainly seen through the 
peritoneal coat of the bowel as deep red, round, or 
oval areas. If the peritoneum which forms their 
base has lost its normal lustre and feels thick and 
infiltrated, the ulcers must be considered on the 
verge of perforation. In two of my cases and in 
several of those operated upon by colleagues at the 
hospital, there were suspicious areas of this kind. 
Sometimes these suspicious spots are so numerous 



50 



MEDICAL RECORD. 



[July 9, 1904 



that they occupy the greater part of the lower one 
to two feet of the ilium with, perhaps, the appendix 
vermiformis and part of the caecum and ascending 
colon, so that it is almost impossible to suture over 
all of them without causing an extensive and too 
great a narrowing of the lumen of the bowel. This 
condition was present in one of my cases in which I 
sewed over only the very worst patches, four in 
number, and had the misfortune to lose the patient 
from the perforation of still another ulcer. The 
post-mortem examination in this case showed that 
the lower foot of the ileum was filled with large and 
deep ulcers. The ideal method of treatment in these 
cases would be the resection of the affected loop of 
intestine — a procedure which is, however, too 
dangerous, and which would no doubt cause so 
much shock that few of the patients would long 
survive it. 

IV. The Manner in Which the Patients Stand the 
Operative Interference. — One would expect that 
patients — the most of whom are already exhausted 
by their long and severe disease — would bear the 
operative interference badly. Fortunately, how- 
ever, this is very often not the case, and, if the 
operative manipulations are done with rapidity, the 
patients seem often to be in better condition at the 
end of the laparotomy than they were at its begin- 
ning. In some way, the removal of the toxic 
material from the peritoneal cavity has an imme- 
diate beneficial effect upon the general condition. 
This improvement may be due in part to the hot 
saline irrigation of the peritoneal cavity, which acts 
not only as a cleansing agent but also as a powerful 
stimulant — an internal infusion. It may also be 
due in part to the morphine which is often given to 
the patients just before the operation. It must be 
remembered in this connection, however, that the 
same methods are usually adopted by us during 
operations for other perforative conditions of the 
gastrointestinal tract. But in the latter I have 
never seen such marked improvement immediately 
after the operative interference. Of the writer's 
four cases, three were in distinctly better condition 
when the operation was concluded than before it 
was begun. The same has been the case in many 
of the patients operated upon by others at Mt. Sinai 
Hospital and in many of the cases reported in the 
literature of the subject. In the cases with a fatal 
outcome, most of the patients did not die from 
shock a few hours after the operation, but they died 
a number of days later from the infection of the 
peritoneal cavity due to the perforation. Several 
patients recovered from the laparotomy but died 
after several weeks from their typhoid fever. The 
remarkable manner in which a large number of these 
patients stand the operative interference has been 
already commented upon by a number of writers, 
especially by Gushing and Finney of Johns Hopkins. 
An important condition for success, as I have just 
mentioned, is that the operative manipulations be 
rapidljr done, with as little exposure of the intestines 
as possible. 

V. The Course of the Disease after the Operation. — 
As is well known, perforation in typhoid fever occurs 
most often during the course of the third to fourth 
week of the disease or during a relapse, at a time 
when the fever is usually still high. In three of the 
patients that I have operated upon, and in several 
of the cases operated \ipon by colleagues at our 
hospital, there was within twelve to eighteen hours 
after the operation a siidden fall of the temperature 
to the normal or near the normal, followed later by a 
rise, but the regular course of the typhoid tempera- 
ture seemed to have been broken. The writer has 
gained the impression that such a fall of temperature 



during the first twenty-four hours after the opera- 
tion has considerable prognostic significance, inas- 
much as four of the five patients that recovered had 
this drop of temperature. It was present only in 
one patient in whom the disease ended fatally, and 
that was a case in which the patient died in sudden 
collapse from a second perforation (see Case IV at 
the end of this article). In this connection it is of 
interest that Hutchinson {Philadelphia Medical 
Journal, January 17, 1903) gives an account of three 
cases in which no perforation was found at operation 
and the abdomen had been flushed with saline solu- 
tion, in each of which there was a distinct drop in the 
temperature for thirty-six hours, after which the 
typhoid fever continued its course and the patients 
recovered. 

In one of my cases the temperature again rose, 
due to the appearance of numerous furuncles and 
abscesses all over the body; in a second case, after 
ten days of normal temperature, the patient had a 
severe and prolonged relapse with high tempera- 
tures and a very rapid pulse, but he recovered.* 

In the patients that recovered, the abdominal 
signs disappeared with considerable rapidity; at 
the end of twenty-four to forty-eight hours, the 
abdomen had become much less distended and ten- 
der, and in four to five days practically all of the 
abdominal symptoms, except those due to the wound 
in the abdominal wall, had disappeared. 

Healing was not essentially different from that 
after laparotomy for perforative peritonitis from 
other causes. The wound in the abdominal wall 
should be drained, as otherwise it is very apt to 
become infected. 

VII. Some Details Regarding the Operative Alatti- 
pulations Which Are of Interest.- — Rapidity is a sine 
qua von for success in operations for typhoid perfora- 
tion. In less than twenty minutes' time it is usually 
possible to open the abdomen on the right side, find 
the perforation and suture it, examine four to six 
feet of the lower ileum, beginning at the ileocascal 
junction, suture over any areas that seem to be in 
danger of perforating, wash oiit the peritoneal 
cavity with hot saline solution, drain the peritoneal 
suture line, and close the remainder of the incision 
in the abdominal wall by an appropriate suture. 
The duration of the operation in the writer's cases 
was II, 18, 14, and 23 minutes respectively. The 
abdominal incision should preferably be made along 
the outer side of the right rectus muscle or through 
its fibers, as the lesion will most often be found on 
the right side of the abdominal cavity, unless the 
physical signs should point to some other part of the 
abdomen. The incision should be a liberal one from 
the very beginning. As soon as the peritoneal cavity 
has been opened, one must look for the caecum and 
ileocaecal junction, and when this part of the bowel 
has been exposed, pull into the wound the most 
prominent loop of small intestine which lies against 
it. In a considerable number of the cases, this loop 
will be found to be the affected one and the perfora- 
tion thus be most quickly found. If there is no one 
loop that is particularly prominent, one must begin 
the examination of the ileum from the ileocaecal 
junction. As soon as the perforated ulcer has been 
found, the opening should be closed by a double 
layer of Lembert sutures passed in the long axis 
of the bowel, so that they will cause a minimum 
amount of narrowing of the lumen of the intestine. 
If the perforation of the bowel wall is so large or the 
infiltration so extensive that simple suture is im- 
possible, one of two procedures can be followed — 

♦The recoverv of this patient was in no little part due 
to the verk- careful watching and treatment of the house 
physician, Dr. Kremer. 



July 9, 1904] 



MEDICAL RECORD. 



51 



either a portion of the omentum can be sewed over 
the opening, or the affected loop of intestine can be 
anchored in the wound by a few sutures, and a fecal 
fistula thus established. Escher" has recently recom- 
mended that the perforation should never be sutured, 
but that the loop of bowel should be anchored in the 
abdominal wound and the bowel drained. Escher 
claims that the operation can thus be done with 
great rapidity, and that the drainage of the bowel 
prevents paralytic ileus and exerts a favorable effect 
upon the peritonitis. It is preferable, however, 
to close the perforation, unless it be too large or the 
surrounding bowel wall too much diseased. In the 
latter condition the method of Escher is surely 
preferable to resection of the bowel. 

If there is any doubt that the intestinal sutures 
will hold, it might be advisable to keep the loop near 
the wound by fi.xing its mesentery or the bowel itself 
to the abdominal wall with a few sutures. 

Any ulcers that seem to be in danger of per- 
forating should be just as carefully sewn over as 
the perforated one. If there are a large number 
of these dangerous ulcers in the lower ileum, it 
is advisable to wall off the affected loop of gut from 
the peritoneal cavity by a small gauze packing on 
each side of it, and thus guard against the danger to 
the peritoneal cavity from a possible later perforation. 

Wherever sutures have been applied to the in- 
testinal wall, it is a good plan to rub a little iodoform 
powder over the suturfe line — through the irritant 
qualities of the iodoform the adhesive process is 
hastened. 

Since the publication of the writer's last paper 
on perforation of the intestine in the course of 
typhoid fever, he has been led to change his views 
on the subject of irrigation of the peritoneal cavity. 
Although we have to depend to a great extent upon 
the absorptive powers of the peritoneum, absorption 
can be hastened and aided by irrigation of the cavity 
with isotonic 0.9 per cent, saline solution. Aside 
from the fact that by this irrigation considerable 
toxic material is removed, it acts also as a powerful 
stimulant, and this function of the irrigating solu- 
tion should not be underestimated. One has onlj' 
to note the immediate improvement in the patient's 
condition in a few cases in order to become con- 
vinced of its value. 

After a thorough irrigation, the smaller the drain 
that is inserted into the abdomen the better. It 
is now well known that drainage of the general 
peritoneal cavity can seldom, if ever, be accom- 
plished. It will generally suffice to pass a small 
strip of gauze or a cigarette drain do-s\Ti to the suture 
line in the intestine or underneath the sutures in 
the parietal peritoneum, and then to close the 
greater part of the abdominal incision. 

In the cases in which the perforation in the wall 
of the bowel is walled off from the general peritoneal 
cavity by adhesions and lies in the bottom of an 
abscess cavity, it is advisable to do nothing more 
than to open the abscess and drain it, leaving the 
perforation in the wall of the intestine to take care of 
itself. The fecal fistula which usually becomes es- 
tablished will often close of itself, as it is situated 
in the lowermost part of the ileum, otherwise a second 
operation maybe necessary later on to close it. 

Many writers recommend that operations for 
typhoid perforation had best be done under local 
ansesthesia. However, the writer would agree 
with those who prefer a general anaesthesia. I 
believe that a fair-sized dose of morphine, followed 
by a light chloroform anaesthesia, is preferable in 
most cases. From my experience in abdominal 
surgery under local anaesthesia, I have learned 
that in most cases the handling of the small intes- 
tine and the straining of the- patient while the 



abdomen is being washed out with saline solution 
contributes more to shock than a light chloroform 
anaesthesia, aside from the fact that under general 
anaesthesia the necessary manipulations can be 
more qiiickly accomplished. 

The after-treatment need differ in no way from 
that after laparotomy for other conditions, with the 
exception that the general feeding miist be that 
of a patient with tj'phoid fever. 

Case I. — Female, six and a half years of age. 
transferred from the service of Dr. Koplik. Per- 
foration on lower ileum on thirty-third day of 
severe typhoid. Before operation, temperature, 
104.4; pulse, 180; respiration, 40. Collapse very 
marked. Laparotomy and suture of perforation 
sixteen hours after first symptom. Seropurulent 
peritonitis, free gas in peritoneal cavity. Duration 
of operation, eleven minutes. Convalescence de- 
layed by furunculosis and multiple abscesses; 
recovery." 

Case II. — Male, eighteen years of age, transferred 
from the medical service and operated upon Sep- 
tember 21, 1903. Perforation in lower ileum in 
fifth week of disease. Laparotomy and suture of 
perforation and of one area on the verge of per- 
foration. Fasces and free gas in peritoneal cavity. 
Duration of operation, eighteen minutes. After 
ten days of normal temperature, severe relapse 
with high temperatures and very rapid pulse; 
recovery. 

Case III. — Male, nine years of age, admitted to 
the hospital and operated upon on August 6, 1903, 
in the third week of typhoid fever, with symptoms 
of general peritonitis of about twenty hours' stand- 
ing. Patient's condition verj- poor, he had to be 
infused upon the operating table. Laparotomy 
with removal of appendix and suture of perforation 
in lower ileum; seropurulent peritonitis. Duration 
of operation, fourteen minutes; recovery. 

Case IV. — Female, nine years of age, transferred 
from the children's service of Dr. Koplik and ope- 
rated upon September 30, 1903. Patient in very 
poor condition. Perforation in lower ileum on 
twenty-seventh day of severe tj-phoid fever. Lapa- 
rotomy and suture of perforation about eight hours 
after first symptom; suture of three suspicious 
areas; fluid and faeces in general peritoneal cavity. 
Duration of operation, twenty-three minutes. After 
eighteen hours, condition of patient fairly good; 
no vomiting, abdomen more soft and not very 
tender; pulse 130 and of good quality. At expira- 
tion of twenty-second hour, sudden change in con- 
dition; collapse, death. The post-jnortem ex- 
amination showed that there was a second perfora- 
tion between two of the sutured areas; the entire 
lower twelve inches of the ileum was filled with nu- 
merous large and deep ulcers; large amount of fecal 
matter in peritoneal cavity. 

REFEREN'CES. 

1. Finney, Johns Hopkins Hospital Reports, 1900. 

2. Cushiiis;, Annals oj Surgery, May, igoi. 

3. Herringham and Bowlby, Medico-Chirurgical Trans- 
actions. Vol. LXXX, p. 127. 

4. Boston Medical and Snrgical Journal, Vol. CXLII, 
No. 26, p. 627. 

5. McCrae, Johns Hopldns Hospital Reports, 1903. 

6. Osier, "Nothnagel's System," American Edition. 

7. Gushing, loc. cit. 

8. McCrae and Mitchell, Johns Hopkins Hospital Re- 
ports, 1902. 

g. Russel, Montreal Medical Journal, 1903, XXXVIII, 
pp. 63—70. 

I o . Fix and Gaillard,.4 rchives de Medecine et de Pharmacte 
Militaires, Paris, 1905, XLI, p 218-230. 

11. Escher, Grenzgebieter der Medizin und Chirurgie, 
Vol. XI, No. I. , , 

12. This case was reported in detail in the Annals of 
Surgery, May, 1903. 

Madison Aves-ue .\nd Sixty-third Street. 



MEDICAL RECORD. 



[July 9. 1904 



A METHOD OF SECURING FIXATION AND 
HARDENING OF THE CENTRAL NERVOUS 
SYSTEM BEFORE THE AUTOPSY.* 

By B. ONUF (ONUFROWICZ). M.D., 

'PATHOLOGIST TO THE CRAIG COLONY. SONYEA. N. Y. 

Whether the method herein described is new 
I do not know. It was new to me and it is cer- 
tainly not generally known, otherwise the com- 
plaint of the inability to preserve the central 
nervous system within a few hours after death, 
consequently the impossibilitj^ of studying the 
finer strvictural changes in a given case, would 
not be heard so often. 

The method is comparable in its simplicity to 
the egg of Columbus. The procedure consists in 
injecting as soon as possible after death a strong 
solution (12 per cent.) of formalin, first by lumbar 
puncture, then through the foramen magnum. The 
former hardens the spinal cord, the latter the brain. 
By use of a T branching tube, both injections can 
be combined in one act. 

The details of the procedure may be varied ac- 
cording to necessity and further experience. 

My first attempt, which proved surprisingly suc- 
cessful, was made with an aspiration needle and 
the Dieulafoy syringe. 




Since then I have learned to use a Davidson ball 
syringe with equal success. It is known that the 
pump of the Dieulafoy syringe can be used in two 
ways, according to the manner in which it is con- 
nected, i.e. either for exhausting the air or for com- 
pressing it. In this procedure it is used for com- 
pressing the air. 

The subjoined illustration shows the manner in 
which the apparatus is put together. It is con- 
venient for the piirpose to use a bottle with three 
mouths. This bottle is filled with the injection 
fluid. Mouth C has a rubber stop through the 
bore of which passes a glass tube down to the bot- 
tom of the vessel. At its upper end this glass tube 
is connected with the rubber tube ZZZ, preferably 
non-collapsible, to which is attached the aspiration 
needle. The latter attachment is by metal con- 
tact only, as is the case with many hypodermic 
needles which fit the barrel of the syringe by con- 
tact only instead of by a thread. Such an arrange- 
ment has the advantage of being easily detachable. 

Mouth B is closed with a common cork or rubber 
stopper. It can be used for refilling the bottle 
when the fluid is almost exhausted without dis- 
turbing the other arrangements. 

Mouth A has a rubber or cork stopper through 
the bore of which passes a T-shaped tube with 
which, by means of a thick-walled rubber tube RRR 

*From the Pathological Laboratory of the Craig Colony 
for Epileptics, Sonyea, N. Y. " » - 



(preferably non-collapsible), the Dieulafoy syringe is 
connected. Stop-cocks of this T-shaped tube has 
to be kept open; stop-cock T of the same tube has 
to be kept closed. It hardly needs mentioning 
that the tube passing through the bore of the stopper 
of mouth A must not go down deep enough to reach 
the fluid. In other words, the bottle must not be 
filled so high as to have this tube immerged in the 
fluid. 

The Dieulafoy aspiration syringe has two out- 
lets, X and Y. If the rubber tube RRR is connected 
with outlet X, the action of the pump will exhaust 
the air in the bottle. If the rubber tube RRR is 
connected with the outlet Y of the pump, the action 
of the latter will, on the contrary, compress the air 
in the bottle. 

The manner of required connection (namely, for 
compression) is indicated by arrows on the syringe. 
Moreover, a few trials will very soon show whether 
the pump is arranged for compression or for ex- 
haustion. 

After the apparatus has been put together in 
working order, one proceeds as follows: 

The aspiration needle is detached from tube ZZZ 
and is introduced into the dural sac in the same 
manner and locality as in lumbar puncture. In 
doing so it is advisable to put the corpse into a 
sitting or semi-inclined position so as to let 
the cerebrospinal fluid accumulate in the 
lowest portion of the' dural sac. 

A trocaris preferable to a needle because the 
latter is apt to become obstructed by fat. There 
ma}^ or may not be an escape of fluid from the 
needle if the puncture is successful. The real 
test of the success lies in the result of the 
pumping, i. e. whether, when the pumping is 
started, the level of the fluid in the bottle is 
lowered. 

After the needle, or trocar, has been intro- 
duced with apparent success, the pump is put in 
action, causing a compression of the air in the 
bottle ABC, pressingthe fluid into the glass tube 
passing through C, and thence into the rubber 
tube ZZ. The pumping is continued until the 
fluid spurts out in a continuous stream from tube 
ZZ . At this moment , tube ZZ is quickly attached 
to the aspiration needle and the pumping is then 
continued. If the experiment was successful, the 
level of the fluid will now become lowered in the 
bottle. In case of doubt a mark designating the 
upper level of the fluid will soon show us whether 
this level is becoming lower or not. If it does 
not sink, this means either that the needle, or 
trocar, has not reached the spinal canal, or that 
the needle is obstructed by fat and other 
material. In such case tube ZZZ has to be 
detached and a wire is passed through the 
needle. If this is unsuccessful, the needle must be 
withdrawn and introduced a second time. 

I may here add that my experiment succeeded only 
after I had introduced the needle for the third time. 
The question now arises how long to continue 
pumping. My experience is that, after a time, 
the fluid sinks \&xy slowly and the pumping be- 
comes very difficult. Moreover, air is heard sizzling 
out around the corks or around the tubes passing 
through the corks, and from time to time the corks 
are forced out of the mouths. This is about the 
time to cease, and this forcing out of the corks 
serves as a safety valve, preventing, in all proba- 
bility, the pressure of the injection fluid on the cord 
from becoming so high as to injure the tissues. 

The idea is first to fill the entire dural sac with 
fluid and after that the whole spinal canal, into which 
the fluid will naturally ooze when the dural sac 
has become entirely filled. 



July 9, 1904] 



MEDICAL RECORD. 



53 



One next proceeds to harden the brain. The 
needle, or the trocar, is introduced into the fourth 
ventricle, at least that is the aim. The skull is 
palpated to locate approximately the foramen 
magnum, then the needle is tentatively introduced 
in the neighborhood of the foramen magnum and in 
a direction presumably parallel to the floor of the 
fourth ventricle. If it strikes bone, it will be rather 
easy to say whether such is the occipital bone or 
the spinous process of one of the upper cervical 
vertebrae. On the whole, it is better at first to 
strike too high, i.e. against the occipital bone. In 
such case the needle is taken out again and intro- 
duced a little lower down. One can thus gradually 
feel his way until he strikes just inward of the 
dorsal margin of the foramen magnum. The needle 
is then pushed deeply enough to enter the fourth 
ventricle, not deep enough, of course, to injure the 
cerebellum or oblongata. Whether the needle 
really needs to enter the fourth ventricle I do not 
know. Indeed it seems hardly necessary since the 
foramen Magendie gives sufficient means of com- 
munication between the ventricle and the surface 
of the cerebrum and cerebellum, so that, if only the 
subdural or subarachnoid space is entered, the 
fluid should have a good chance of being distributed 
over the surface of the cerebrum and cerebellum 
as well as to the ventricles. 

The particulars will have to be learned by ex- 
perience. Injurj- to the adjacent parts, cerebelkim 
and oblongata, should of course be avoided. In 
my case neither of these structures showed any 
evidence of injury; but choosing between two evils, 
injurj- of the cerebellum would, on the whole, seem 
less harmful, special cases excepted, than injury of 
the oblongata. By keeping well in the median 
line, injury to both the.se parts can probably be pre- 
vented. If the needle should enter into the brain 
substance, this would soon be shown by the failure 
of pressing the fluid in, after the needle has been 
reconnected with the pumping apparatus and the 
pumping commenced. In case of success, the level 
of the fluid in the bottle will soon become visibly 
lower. As to the quantity of fluid to be used, I 
may say that, in my first attempt, about one-half 
pint was introduced into the brain and about four 
ounces into the vertebral canal. 

Whether it is necessary to use a Dieulafoy as- 
piration, or rather compression, syringe for the in- 
jection, I cannot tell. As I have mentioned already, 
the same results may be obtained with the much 
cheaper Davidson syringe or with a similar ball 
syringe, in which case the bottle described can be 
done away with. Let me also repeat here, that by 
the use of a T branching tube, one end of which is 
connected with the pumping apparatus, the second 
end with the aspiration needle, passing into the 
lumbar sac, and the third end, with the needle 
passing into the forameg mannum, the two injec- 
tors, -i.e. that into the ducal sac of the spinal cord, 
and that through the foramen magnum, can be com- 
bined in one procedure, thus saving time and equal- 
izing the pressure of the fluid. 

I shall now relate the results of the injection in our 
first case, which was made about one hour after death. 
First, however, let me mention that the body was 
then placed in the ice-box in usual position, i.e. 
lying on the back. This is, of course, the most 
common position, but there is a particular reason 
for mentioning it, as will be seen later. 

The autopsy was made forty-three hours afte^" 
death, the body being left meanwhile in the 
ice-box. The peculiarity was then noticed that the 
fat of the abdominal wall was of an abnormally 
firm, waxlike consistency and of a dark, dirtj^ 



brown-gray color, while that of the thoracic wall 
had the usual appearance and consistency. On 
opening the abdomen, the fat of the mesentery in 
the lower portion of the abdomen was found to have 
the same peculiarity as that of the abdominal wall. 
I suspected that this was due to the effect of the 
formalin. 

Further examination showed that a great portion 
of the liver also had a peculiar appearance, and here 
there was no doubt that such was due to the effect 
of the formalin, since the tissue in some parts looked 
whitish and was so hard that no other explanation 
was possible. I then felt certain that the peculiar 
fat referred to was due to the same cause. 

First I was at a loss to account for this fact, but it 
now seems clear enough. It is natural to assume 
that, after the vertebral canal became filled with the 
injection fluid, it began to penetrate through the 
foramina intervertebralia into the surrounding tis- 
sues. It should be added, however, that the lungs, 
heart, spleen, pancreas, and kidne3^s showed no for- 
malin effects, which is of value to know, as it shows 
that the spinal cord and brain may be preliminarily 
hardened without diminishing the value of an ordi- 
nary autopsy, to be made later on. 

As to the effect of the injection on the spinal cord 
and brain, it surpassed my most sanguine expecta- 
tions. The spinal cord was completel)' hardened in 
its entire length and thickness, as shown on a trans- 
verse section made through the middle dorsal region 
and as shown by its hard consistency through the 
entire length. 

The brain also was, to all appearance, more or 
less hardened throughout. It showed the same 
elastic hardness which a brain shows after injection 
of a lo-per-cent. solution of formalin into the aorta 
(with tying off of the thoracic aorta), as practised by 
Drs. Adolf Meyer and Dunlap at the Pathological 
Instittite of the New York State Hospitals. 
Twenty-four hours after removal of the brain the 
Meynert section was performed, i.e. the pallium 
(hemispheres) was separated from the rest of the 
brain. It was then shown that the formalin had 
penetrated everywhere. The hemispheres were 
found hardened in their whole thickness. The basal 
ganglia were also hardened, although in varying de- 
gree — the caudate nucleus less than the thalamus; 
but all parts showed the effects of the formalin. An 
absolute hardening of all parts could, of course, not 
be expected; but the important fact was noticed 
that no part showed any post-mortem decomposi- 
tion, i.e. softening and putrefaction. Without the 
formalin such changes could have been expected 
with certainty, in view of the fact that the autopsy 
was performed forty-three hours after death, even 
although the body was in the ice-box all this time. 
However, the most valid proof and most delicate 
test of the preserving and fixing value of the 
method was given in its influence on the neuroglia. 
That this tissue suffers very quickly through post- 
mortem disintegration is known to everybody 
familiar with it, and if in a given brain the neuroglia 
stains well, this is always a proof of early preserva- 
tion and flxation of the brain. In the first case in 
which the method of preliminary formalin injection 
was made one hour after death, and in which the 
autopsy was performed forty-three hours after death, 
pieces from four different regions, namely, cerebral 
cortex, cerebellar cortex, medulla oblongata and 
caudate nucleus, were removed twenty-four hours 
after the autopsy and subjected to the procedures 
required for the Mallory Phosphotungstic-hema- 
toxylin neuroglia stain. The stain succeeded very 
well in all four regions, but of particular value was 
its success in the caudate nucleus which, as men- 



54 



MEDICAL RECORD. 



[July 9, 1904 



tioned above, was softer than the other parts of the 
brain, i.e. not so well acted upon by the formalin. 
How well it succeeded is seen by the adjoining fig- 
ure showing the neuroglia fibers and neuroglia 
nuclei of a part of the caudate nucleus. The pene- 
trating value of the method is thus very aptly 
shown. 

The great value of the method needs hardly 
to be emphasized. Every neuro-pathologist knows 
how important it is to fix and harden the cen- 
tral nervous system no later than six hotirs at 
the most after death. Here, we have means of 
preserving it immediately after death without in- 
flicting any mutilation on the body and without 
changing the appearance of the intra-thoracic and 




Figure showing a portion of the caudate nucleus stained with Mallory's 
phosphotunKStic-hematoxylin neuroglia stain. Taken with Leits' 
ocular 4 and immersion 1-12 in. 

intra-abdominal organs (with the exceptions men- 
tioned) through the formalin. 

The method has this advantage over the other- 
wise excellent method of formalin injection into the 
aorta as practised by Drs. Meyer and Dunlap, and 
elaborated in such an ingenuous manner by these 
gentlemen — it can be applied immediately after 
death in cases in which we are doubtful whether an 
autopsy will be permitted or not. 

It has the further advantage over that method, of 
hardening not onh' the brain, but also the spinal 
cord; and the result is not inferior to that of their 
method. 

An additional advantage is the small quantity of 
formalin required, one quart at the most being 
needed as against the i^ to 3 gallons necessitated in 
Meyer's and Dunlap's method; and this advantage 
is not to be undervalued in view of the relatively 
high price of this drug. 



OCCIPITOPOSTERIOR POSITIONS.* 

By S. MARX, M.D.. 

NEW YORK. 

When I was requested to open the discussion on 
" Occipitoposterior positions." I thought that the 
last word had been said on this subject — that 
is, so far as the reader is concerned. The question 
of the management of occipitoposterior presenta- 
tions has resolved itself into one of relative sim- 
plicity, not that any particular schematic thera- 
peusis will be offered; for schemes in obstetrics, 
as well as in other specialties of medicines, often 
go wrong, but the experience offered by meeting 
many of these cases has allowed me to present 
fixed, though hardly dogmatic, views on the sub- 
ject before us, for it is the belief that a finality 
has been reached with this question, as well as 
with many other obstetric questions. To be 
forewarned as to this complication is to be fore- 
armed. It is far more frequently met than is usually 
thought and taught. But it occurs most frequently 
as a primary condition and at so early a stage is 

*Discussion opened before the Obstetric Section, New 
York Academy of Medicine, April 2S, 1904. 



certainly not recognized or is not sought for; for 
it does not enter the mind of the attendant 
that it is possible to have a malposition of a normal 
presentation. Of my own personal statistics, I 
quote from my case book that in the last one hun- 
dred consviltations in midwifery I have come in 
contact with twenty-three cases of persistent occipito- 
posterior positions. This, of course, does not carry 
with it much importance as to the absolute fre- 
quency of this complication, for as a consultant it 
is most natural to see nothing but complications. 
But of more importance is the careful review of the 
cases under my personal care, i.e. private cases — 
those examined from the onset of labor and in 
which there has been an early determination of 
the position, before the head has been markedly 
influenced. Here I have noted, in one hundred 
cases, seventy primarily posterior occiputs, cer- 
tainly a larger percentage than I had any idea of; 
and we doubt not that if all practitioners took 
the necessary care for a careful and early ex- 
amination the same high percentage would be 
found. For this reason I wish to record the fact 
that primary malpositions of the occiput are 
present in a much larger number of cases than we 
are led to believe. How much higher still the 
percentage may be before the advent of labor is 
impossible to tell, except by abdominal palpation, 
but for reasons elsewhere given I pin my faith 
on internal examination, relegating abdominal 
palpation to the position to which it belongs — name- 
ly, one of absolute unsafety. 

And this leads up to the question of diagnosis. 
Even without an internal examination, the symp- 
toms presented are so characteristic that a presump- 
tive diagnosis can very often be readily made, and this 
triad of symptoms ought always be associated with 
a possible vicious presentation of the occiput, i.e. 
early rupture of the membranes, slow nagging and 
teasing pains and abnormal slow and futile labors. 
Such evidence can always be clinched by a vaginal 
examination, or, if the least doubt exists, the in- 
troduction of the full hand into the canal. It is 
absolutely essential for successful treatment to make 
an early and a clear diagnosis not only of position, 
but of presentation; and in this I am sorry to say 
too little is done, for the average practitioner always 
rests satisfied so long as the hard head presents, caring 
little or bothering less what area of the fetal head 
present. Earlj* recognition and timely interference 
is more than half the battle won, for by such means 
we can, in an overwhelming majority of cases, change 
the case from an almost impossible one to one of 
the greatest simplicity, and thus carry it to a suc- 
cessful issue. But of the greatest import is still: 
What are you going to do in order to cope success- 
fully with these cases? It must be remembered 
that a firmly flexed head will almost always rotate 
spontaneously, and that the first step in the treat- 
ment of these cases is to insure a permanent and 
marked flexion; and this can be most readily done 
by pressing, throughout several pains, the sinciput 
against the chest of the child by two fingers, or 
the introduction of the full hand in its grasp, flex- 
ing the occiput and thus obtaining the same re- 
sult. The permanency of this sustained flexion 
is assured by using the postural treatment, i.e. 
placing the patient in that lateral prone position 
corresponding to the position of the occiput. These 
minor manipulations done early and carefulh', as 
above described, will, in the great majority of cases, 
cause the head to rotate with resultant normal and 
spontaneous expulsion. It is advisable to under- 
take operative measures at a late period ; or, 
to be more concise, operate only when there are 



July 9. 1904] 



MEDICAL RECORD. 



55 



present, symptoms to indicate that interference is 
warranted, symptoms the interpretation of which 
mean exhaustion on the part of the mother or child. 
In obstetrics early and uncalled interference is un- 
warranted and may lead to disastrous ends, while 
working in armed expectancy is often followed by 
remarkable and favorable results for mother and 
child, if only for the reason that in this complication, 
rotation occurs in a large majority late, i.e. when 
the head is low down on the pelvic floor. The 
secret of success lies in two directions: (i) operate 
only in the face of clear indications on the part of 
either mother or child ; (2) operate at once when there 
is tendency to posterior rotation. 

When either of the just mentioned conditions 
arise how are we to meet them? 

Cassarean section and symphyseotomy are included 
for the reason that we presuppose that we are 
dealing with a pelvis that is normal, and consequently 
these operations are beyond the scope of this paper. 
Yet it occasionally may happen that either one of 
the just quoted operations might have to be con- 
sidered, especially the pubic section, in those rare 
cases in which the occiput is absolutely impacted and 
no other means can possibly give us a living child. 

In quite a few of these cases, the perforator ought 
always be the instrument of selection, for it would 
be the height of folly and directly against the 
interests of the mother to attempt to deliver by 
another means than by a craniotomy upon a child 
whose life has already been sacrificed or at best 
whose vitality is so low that any form of operative 
measure would deliver a dying or hopelessly maimed 
child. A rule which I strictly adhere to, so far as 
circumstances allow, is to elect the perforator in 
all those conditions just mentioned, only in the 
presence of a child of good vitality I should elect either 
forceps or version, and my selection of these methods 
is practically sharply defined, i.e. version when the 
head is above the brim, forceps when the head is 
fixed at or below this point. What I wish to 
elucidate in this paper is the absolute value 
of the modern axis traction forceps. But I would 
preface my remarks by a note of warning. The 
modern axis traction is a dangerous instrument for 
the inexpert, even as it is absolutely safe in the 
hands of one accustomed to its use. It is a forceps 
for the expert only; and if by its use bad results 
accrue it is not the fault of the forceps, but of the 
operator. Its method of application and its 
action have been more fully gone into in another 
paper and cannot be entered into more fully 
here. But one important method of delivery will be 
discussed at length, and that is the method which has 
given almost uniform success and satisfaction. I 
have given it the name of "rotary axis traction," 
for by this manoeuvre we fulfil a compound in- 
dication, i.e. axis traction and, at the same time, 
artificial rotation. These, as j^ou will readily see, 
are particularly applicable to cases of posterior 
position of either the vertex or the face. I cannot 
improve upon my statements made in a former 
article and shall take the liberty of quoting the 
following from the same : In many of these cases of 
occipitoposterior positions I have succeeded, by the 
use of the Tarnier instrument, in rotating the 
head anteriorly by simply allowing it, while traction 
is being made, to be influenced by the factors 
supplied by nature (the resistance offered by the 
perineal structures and furthered by the turning 
points afforded by the ischial spines, especially 
when they are prorninent) to provoke such rotation. 
And herein lies the utility of the instrument. It 
allows the head to pass uninfluenced through the 
pelvic canal, except for the natural influences which 
promote rotation; hence the great advantage is the 



free mobility of the forceps when applied to the 
head. This rotation begins to occur when the head 
descends to the pelvic floor, and is instantly evinced 
by the behavior of the blades — they begin to rotate 
with the head, the movement increasing with ever}'' 
traction effort, until the forceps has entirely rotated. 
When, however, such tendency to rotation does not 
occur, the normal mechanism is probably at fault, 
and it is then that "rotary axis traction" becomes of 
supreme value. The forceps may be applied ac- 
cording to the pelvic walls; but an oblique applica- 
tion, i.e. to the sides of the child's head, is better. 
When in such position, it conforms to one of the 
oblique diameters of the pelvis, insures a more certain 
grasp, and very materially aids in the success of this 
otherwise rather simple manoeuvre. With the right 
hand, steady traction is made, and at the same time, 
with the left hand, the handles of the forceps are 
compelled, or at least influenced, by gentle rotation 
to turn in the direction of the presenting part; to 
the left in left occipitoposterior cases, to the right in 
right posterior ones. This manipulation must be 
persisted in, slowly rotating all the time while 
making careful and intermittent traction, timing 
our measure so that when the head reaches the 
pelvic outlet, complete rotation shall have occurred 
and the forceps blade shall be found nearly or 
entirely inverted. At no time should brute force be 
used, but the greatest gentleness exercised at all 
times. I have on a number of occasions tried 
forcible rotation by the ordinary forceps, and have 
succeeded, but often at the expense of the maternal 
structures, with resulting deep tears of the vagina 
and pelvic floors. "Rotary axis traction" has 
been tried innumerable times, and it has seldom 
failed when the forceps was applied to the sides of 
the pelvis, and never* when it was applied to the 
sides of the fetal skull. The resultant lesions were 
no deeper or more frequent than in ordinary simple 
forceps extractions. The prognosis for the child 
was as good as under ordinary conditions. ; 

♦Since writing this article, however, I failed in one case 
to rotate even though the blades were applied to the 
sides of the fetal skull. 



BRIEF NOTES ON THE MANAGEMENT OF 
OCCIPITOPOSTERIOR POSITIONS OF THE 
VERTEX. 

LY JOHN O. POL.\K, M.S., M.D., 

BROOKLYN. N. Y. 
'professor of obstetrics, N. Y.rpOST-GRADUATE MEDICAL SCHOOL. 

The occurrence of a posterior position of the vertex 
is always indicative of faulty mechanism, it matters 
not whether the fault be a pelvic contraction of the 
flattened, general, oblique, or kyphotic form, a large 
head, a small child or a defective pelvic floor, imper- 
fect flexion of greater or lesser degree, always occurs 
at some stage of the mechanism. Consequenth'' 
when this malposition does present, it suggests some 
defection in the factors of labor and a recognition 
of the cause in the particular case must be appre- 
ciated before any treatment can be instituted. 

Diagnosis. — Before labor and during the early 
part of the first stage, the diagnosis of occipito- 
posterior may be readily made by abdominal palpa- 
tion. The dorsal plane is inaccessible, while the 
small parts are prominent and found in the middle 
section of the abdomen. The head is usually not 
engaged at the beginning of labor, which makes the 
cephalic prominence marked. The anterior shoulder 
is found remote from the median line and the heart 
is heard well around toward the flank or not heard 
at all. Right occipitoposterior must always be 
thought of in right dorsal positions, as it occurs 
nearly or quite as frequently as a right anterior posi- 
tion. Aleftposterior is less frequent than a right. The 



56 



MEDICAL RECORD. 



[July 9, 1904 



vaginal signs are confirmatory. If the head is 
engaged, the small or posterior fontanelle may be 
felt opposite one or the other sacroiliac synchron- 
drosis with the ball of the occiput posterior. Usu- 
ally, however, the head is not engaged at the begin- 
ning of labor, and further it is frequently improperly 
flexed, because of the conditions which obtain, in the 
causation of posterior occiputs. Hence the large 
fontanelle is at a lower level and is more easily felt. 
Palpation of the ball of the occiput and the relative 
location of the ears will make the diagnosis positive. 
It must be kept in mind that the most frequent 
cause of fetal dj'-stocia is a posterior position of the 
vortex and when such is encountered, should there 
be any doubt in the mind of the operator as to the 
relations of the head to the pelvis an examination 
under anaesthesia with the hand in the vagina and 
two fingers or half the hand introduced into" the 
uterus will remove all uncertainty. The relation 
that the sagittal suture bears to the diameters of the 
pelvis is a constant index as to the degree of rotation 
and must be observed to manage intelligently this 
abnormality. 

Treatment. — The majority of posterior cases rotate 
to the front unaided when the passenger, powers and 
passages are normal or can be made to assume rela- 
tive normality. Less than 2 per cent, rotate into 
the sacrum, notwithstanding that the head must 
rotate through 135" to be delivered with the occiput 
under the pubes. This rotation takes place either 
at the brim, in the cavity of the pelvis or on the 
pelvic floor. 

When the diagnosis is accurately made in the be- 
ginning of labor, posterior positions are not as for- 
midable as general!}- believed. The dangers to the 
mother are exhaustion, lacerations, and the risks of 
instrumental interference. To the child — those of a 
prolonged labor. In considering the management of 
this abnormality, it is advisable to study the indi- 
vidual case as it presents at the time when it is seen 
by the accoucher. 

Therefore I would classify these conditions as fol- 
lows: 

1. With the head at or above the brim, flexion 
more or less imperfect, and the membranes unrup- 
tured. In the presence of these conditions, 
postural methods alone deserve our consideration. 
The woman should be placed on the side toward 
which the occiput points and directed to maintain 
this position, which favors anterior rotation and 
more perfect flexion of the vertex. The genu- 
pectoral position which is mentioned in most of our 
textbooks cannot be maintained by the patient 
for any length of time and so is only of theoretical 
value. Every effort should be made to keep the 
membranes intact until complete dilatation of the 
cervix is obtained. When dilatation is slow a 
colpeurynter will facilitate canalization and preserve 
the membranes. 

2. After rupture of the membranes with the head 
at the superior strait, postural methods may be con- 
tinued while efforts are being made to dilate the 
cervix with hydrostatic bags, unless the condition 
of mother or child demand more radical intervention. 

After dilatation, a fair trial having been given to 
posture and the natural forces having failed to rotate 
the head to the front, manual rotation of the head 
to the front and engagement of the head by internal 
and external manipulation, under anaesthesia, may 
be attempted. This procedure presupposes a dilated 
or dilatable cervix. The one hand placed on the 
mother's abdomen pushes the anterior shoulder 
toward the median line, while the other hand in the 
uterus pushes the other shoulder in the opposite 
direction, thus rotating the dorsum anteriorlj', as 



well as the head, and the tendency to recurrence is 
minimized. When the malposition of the occiput 
has been corrected, an attempt to engage the properly 
flexed and positioned head may be made with the 
patient in the Walcher position, either by crowding 
the head into the pelvis manually or by tentative 
traction with the axis traction forceps. Should this 
attempt to engage the head fail, podalic version 
may be elected, except when the size of the child 
would contraindicate such a procedure. The writer 
feels that while version is theoretically the proper 
thing to do in these posterior cases, which have 
resisted the several eff'orts of the operator to flex 
and engage the vertex, experience in estimating 
the relative size of the child and the pelvis as well as 
the individual dexterity- of the operator will largely 
determine whether an axis traction delivery or a 
podalic version shall be elected. 

When the head presents as an occipitoposterior 
in the cavity, anterior rotation maj^ be favored by 
posture, used in conjunction with manual aid during 
the pain, by pushing the sinciput upward and back- 
ward, thus promoting flexion and anterior rotation. 
Should the head become arrested and remain sta- 
tionary for two hours in the second stage, the forceps 
may be applied, either to the sides of the pelvis and 
taken off and reapplied as the head assumes its rela- 
tion to the different pelvic planes or the axis traction 
forceps may be applied to the sides of the head and 
be used as rotators as well as tractors, guided by the 
relation of the saggital suture. 

When a posterior vertex is encountered on the 
pelvic floor, the occiput maj^ be rotated to the front 
manually or with the reversed forceps, though this 
possibility only obtains in the case of a small foetus 
on a relatively roomy pelvis. Should attempts at 
rotation of the occiput fail and a posterior position 
persist, the brow may be pushed upward to exag- 
gerate the flexion while the occiput is slipped over the 
perineum with more or less tearing of the pelvic floor. 

Posterior positions are apt to tire the woman and 
exhaust the child. The foetus often becomes asphyx- 
iated while in the vagina. The judicious use of 
forceps will minimize these risks. 

In conclusion I would add, make the diagnosis and 
then apply such treatment as the individual case 
demands, being governed by the existing conditions 
at the time at which the patient is seen by the 
attendant. 

287 Clinton Avenob. 



Exanthematous Eruptions Following Throat Operations. 

— From his personal expcrifncc and from a careful study 
of the literature of the subject, Louis Fischer believes that 
exanthematous eruptions, such as scarlet fever or measles, 
have nothing to do \\'ith the operation itself. The in- 
fection evidenth' takes place before the operation. The 
period of incubation may have been shortened, and that 
the disease appear sooner owing to the traumatism. The 
question of prophylaxis by means of local pharyngeal 
antisepsis to destroy pathogenic bacteria in these regions 
is one that deserves attention. It is important to ascer- 
tain, if possible, whether or no the patient has been ex- 
posed to any infectious disease for a number of days prior 
to the operation. The thermometer is of valuable as- 
sistance. If the temperature is above normal it is 
better to postpone operative procedure until normal 
conditions are established. Fischer believes the infection 
takes place before the operation, and that the operation 
itself lowers the resistance of the body, and shortens the 
period of incubation. This \vi\\ account for all of his 
cases and those reported by many clinical observers, being 
called surgical scarlet fever, when in reality they are true 
cases of scarlet fever, infected prior to the operation. — 
The Laryngoscope. 



July 9- 1904] 



MEDICAL RECORD. 



57 



Medical Record: 

A Weekly Journal of Medicine and Surgery. 



GEORGE F. SHRADY, A.M., M.D., Editor. 

THO.MAS L STEDMAN, A.M., M.D., Associate Editor. 



PUBLISHERS 
WM. WOOD & CO., 51, Fifth Avenue. 

New York, Jaly 9, 1904. 

AUTOINTOXICATION OF INTESTINAL 
ORIGIN. 
The question of antointoxication is treated quite 
extensively by Dr. G. Lyon in the Gazette des Hopi- 
iatix for May 14 last. The intestine is a permanent 
sotirce of poisons, which under certain conditions 
cause grave alterations in the principal organs 
(notably the liver, kidneys, and skin) and functional 
troubles, among which those of the nervous system 
occupy a prominent place. Autointoxication may 
exist in connection with diseases involving diarrhoea, 
but it is above all associated with those causing 
constipation; it is, in short, a consequence of all 
intestinal affections. 

To understand its genesis, we must at the outset 
recognize that digestion is a double process, an 
enzymic and a microbic one. Both enzymes and 
microbes transform starch into sugar, both emulsify 
fats, and both transform albuminoids into peptone. 
But the role of the microorganisms does not end 
here, for they may act to bring about further and 
putrefactive changes, with the formation of sul- 
phuretted hydrogen, lactic and butyric acids, and 
from the albumins the ptomains and substances of 
the aromatic group. Against the poisons so pro- 
duced, the normal organism manages to protect 
itself principally through the action of the in- 
testinal epithelium and the liver which destroy the 
majority of the toxic products, while the excretory 
organs eliminate the remainder. Given certain 
conditions, however, and the toxic products can be 
generated in excess of the powers of the organism to 
dispose of them, or those powers may fail in point of 
efficiency. Of these two conditions, the former is 
the more frequent. Various influences may in- 
terfere with the normal course of digestion. 
Errors in diet, qualitative or quantitative, may 
form the starting-point, or the cause may He 
in the organism itself. Thus gastric atony, 
whether combined (as is frequently the case) with 
dilatation or not, plays an important r61e. Or 
any one of several modifications of the gastric 
juice may initiate the series, by entailing delayed 
digestion which means fermentations and putre- 
factions. But gastric conditions are as nothing 
compared to intestinal, as gastric defects can be 
made up by intestinal over-exertion, while for in- 
testinal deficiencies there is no compensation. Apart 
from organic obstructive conditions, intestinal 
atony plays a frequent and very deleterious part, 
the more serious the higher in the intestine the 
stasis occurs. For once stasis sets in, we are already 
in sight of autointoxication. Another expression 



of this motor insufficiency is the constipation so 
often pre-sent. As other pathological conditions 
underlying autointoxication are enteritis (acute 
or chronic), colitis with constipation, cancer of the 
intestines, etc., but especially chronic appendicitis, 
as its rdle is in a number of cases misconceived. The 
fetid diarrhoea, which is very frequent in the last 
disease, and which is very rebellious to treatment, 
ceases at once upon ablation of the appendix. 
Autointoxication may then be associated with any 
disease of the intestines, those associated with 
diarrhoea as well as those connected with con- 
stipation, but it is far more frequently associated 
with the latter class. 

The diagnosis of chronic autointoxication is 
easily made ; the yellowish tint of the face with the 
coated tongue, fetid breath, anorexia, nausea and 
sometimes vomiting, constipation, or diarrhoea 
with fetid stools, usually emaciation, sad aspect, 
with loss of energy and inaptitude for work, the 
whole gamut of nervous troubles (migraine, torpor, 
vertigo, insomnia, multiple pains), make up the 
picture. 

As regards the degree of intoxication taking 
place, the severity of the clinical symptoms affords 
no accurate indication, and the same is true of the 
examination of the stools. Some patients have 
numerous very offensive stools with few symptoms, 
while others with a few apparently normal stools 
show a profound intoxication. It is then impor- 
tant to recognize that we have in the condition 
of the urine (in which the majority of the toxic 
products is excreted), a quite accurate index to the 
state of affairs. Besides the bodies produced by 
both enzyme and microbic action, the micro- 
organisms of the intestinal tract are capable of 
giving rise to putrefactive products; bodies belong- 
ing to thefatty|series (ammonium butyrate,caproate, 
valerianate; ptomains), and to the aromatic series 
(phenol, paracresol, indol, scatol, aromatic 
oxyacids). These appear in the urine as sulpho- 
compounds, their toxicity having been attenuated 
by combination in the liver with sulphuric and 
glycuronic acids. The aromatics have not the 
toxicity of the ptomains but they are excreted 
parallel with them, and constitute, therefore, a 
rather exact index to the amount of the ptomains. 
A number of observations have now shown that 
putrefaction of the food in the prima vias is the only 
source of the "ethereal sulphates" in the urine, and 
that they are never derived from any of the albumi- 
noids of the organism itself. Thus, in animals with 
sterilized intestines, fed with sterile food, the urine 
shows no trace of phenol, indol, or scatol. More 
important, from the practical standpoint, is the fact 
determined by White, Poehl, Herschler, Winter- 
nitz, and Bernacki, that limitation to a hydro- 
carbonaceous diet, brings about a reduction of 
these substances in the urine to one-third of the 
previous amount. On the other hand constipation 
increases the amount of the ethereal sulphates in 
the urine, as does also all obstructive conditions 
of the intestines. The latter fact would naturally 
lead one to suppose that purgatives would bring 
about a decrease. But the action of these drugs 
is, in fact, not a uniform one, castor oil and the 
salines increasing the amount of the urinary ethereal 
sulphates, while calomel decreases them markedly.. 



58 



MEDICAL RECORD. 



[July 9, 1904 



As regards successful treatment, the first indica- 
tion is the retardation of the existing intestinal 
putrefaction. For this purpose sterilization of 
the intestine by means of drugs has been tried, 
but the practice is to-day discredited as an im- 
practicable Utopia. The effects of naphthol and 
its derivatives are, it must be said, much disputed 
and most disputable. Besides naphthol exercises 
an irritation of the most active description on the 
stomach, and its prolon;j;c(l use can cause glandular 
atrophy. Also the administration of hydrochloric 
acid is useless, at an}'^ rate as regards intestinal 
antisepsis, and it may be remarked that hyper- 
chlorhydria does not include antisepsis in its sympto- 
matology. The same is. however, not true of 
lactic acid, which diminishes markedly the urinary 
ethereal sulphates. 

It is, however, by diet that the effect is to be 
produced. To start with, the albuminoids are to be 
reduced to a minimum, for it is their fermentation 
which yields the toxins. Combe recommends 
"saturation" of the patient with hydrocarbona- 
ceous articles of diet, the word "saturation" being 
taken in its most literal acceptation. This anti- 
putrefactive diet of Combe yields the most ex- 
cellent results. Also Poehl and Bemacki have 
proven that a milk diet diminishes the ethereal 
sulphates, and that on such a diet the stools contain 
no indol, scatol. or phenol, but only leucin and 
tyrosin. This resistance of milk to putrefaction 
is attributed by Winternitz to the contained lactose, 
which on fermentation produces lactic acid which 
in its turn inhibits putrefaction. Similarly, fresh 
cheese has been shown to possess antiputre- 
factive properties. As regards eating, meals should 
be alternately solid and liquid, the patient not eating 
when he is drinking, or vice versa. Rovighi and 
Schumann have shown that this course involves a 
diminution of the ethereal sulphates. After each solid 
meal the patient should lie down, without sleeping. 
Green vegetables and all fruits, cooked or raw, are 
to be excluded. After a variable time the milk- 
farinaceous diet is to be mitigated on trial with 
meat, the yolk of eggs, and green vegetables. 

Enteroclysis has more value than as an enema. 
The water is absorbed, relieving thirst and assisting 
in the lavage of the blood. The tube should be in- 
troduced with the patient lying on the right side 
with the left leg flexed upon the abdomen, and very 
slowly with successive pauses, to allow of an un- 
folding of the rugae in advance of it. The solution 
is best an isotonic one (7 parts of sodium chloride 
per 1,000) introduced at 38°, and under a low pressure 
(with an elevation of only 15 to 20 centimeters), 
to avoid spasm of the intestine. Purgatives and 
lavage should be alternated. The purgative of 
election would seem to be calomel. 

In certain cases with profound intoxication (as 
evidenced by nervous troubles, oliguria, subicterus, 
etc.) in which an immediate effect is urgently 
demanded, subcutaneous injections of saline 
solutions are to be resorted to, as this is the onlv 
method which can be relied upon for a rapid de- 
intoxication of the organism. 

The immediate symptoms being relieved, in the 
further treatment recourse should be had to hydro- 
therapy, open-air life, exercise, subcutaneous 
injections of sodium cacodylate and of strvchnine; 



and gastrointestinal massage is one of the best 
means at our disposal for the correction of the 
stasis. 

PARATYPHOID FEVER. 

In the Scottish Medical and Surgical Journal for 
May is a paper by Dr. R. D. Keith on paratyphoid 
fever. The first part of the article is devoted to a 
consideration of the disease chronologically, and 
states that the first case was described by Achard 
and Bensaude of Paris in 1896, who isolated a 
paratyphoid bacillus. Schottmuller of Hamburg 
was the first observer to take up the subject in 
Germany, who isolated the specific organism of the 
disease and gave to the fever the name paratyphoid 
on account of its close resemblance to typhoid fever. 
Schottmuller concluded, from the investigation of a 
large number of cases of clinical typhoid in the 
General Hospital of St. George in Hamburg, that 
the bacilli isolated were the cause of the disease, and 
that of six cases there were two groups, one of which 
contained two, and the other four bacilli. These 
two groups, subsequently described in the literature 
as type "A" and type "B," differ in degree both 
culturally and in their serum reactions. It was 
found that the serum reactions of the members of 
the first group corresponded with one another, but 
not with those of the second group, and that while 
the serum reactions of the members of the second 
group corresponded with one another they differed 
from those of the first. These conclusions in all 
important details have been confirmed by the 
investigations of many observers, including several 
Americans. 

As to the clinical characteristics of paratyphoid 
fever, observations of more than one hundred cases 
have been published, of which, however, only 46 
are available for the purpose of a minute clinical 
analysis. Dr. Keith describes the disease — although, 
as he confesses, somewhat loosely — as an acute in- 
fectious process caused by a bacillus closely re- 
sembling in many particulars the typhoid bacillus, 
and the symptoms and course of the disease closelv 
resembling those of typhoid fever. The onset is 
marked by headache, lassitude, loss of energy, and 
general weakness. Occasionally there is epistaxis, 
and in some cases vomiting and pain in the abdomen. 
By the time the patient comes under observation he 
is feverish and may feel chilly, but regularly marked 
rigors are hardly ever met with. As a rule, the 
temperature does not rise above a moderate height 
(102° F. or thereby), except in the more severe cases, 
nor does it remain for more than a few days at this 
height continuously. 

Occasionally a critical fall is observed, and it has 
been observed by most investigators that even at its 
height the temperature has, as a rule, a remittent or 
intermittent character. The pulse is, as a rule, quite 
regular but somewhat small. Its frequency, accord- 
ing to some, is not increased at the commencement of 
fever. 

A roseolar eruption resembling that of typhoid 
fever was present in thirty-two out of forty-six 
cases. It was described in some cases as occurring 
not only on the skin of the abdomen and chest but 
also on the back and limbs, and in one case even on 
the face. The tongue is generally covered with a 
moist white coating, but is occasionally dried and 
furred. 



July 9, 1904] 



MEDICAL RECORD. 



59 



Diarrhoea is more prominent than constipation, 
and is sometimes present at the commencement of 
the disease. The abdomen is not, as a rule, markedly 
distended, nor is tenderness a prominent feature, 
but pain is in some cases present, and iliac gargling 
is an almost invariable accompaniment of the 
disease. The spleen is enlarged in the majority of 
cases, but so far as can be ascertained during life 
the liver is not affected. The urine during the 
course of the disease shows a deposit of lithates. 
Albuminuria, when present, is, as a rule, not marked 
and is found during the height of the fever. Hyaline 
and granular casts have been observed, and in one 
case blood was found to be present. In nineteen 
out of forty-six cases the urine was found to give 
the diazo reaction, and in eight the test for indican 
was positive. The heart is practically always un- 
affected. With regard to the lungs, bronchitis is 
comparatively common, and emaciation is not so 
marked in this disease as in typhoid fever. 

Of the complications observed, bronchitis is the 
most common. Pharyngitis is not uncommon, and 
next in frequency to it comes bronchopneumonia. 
Thrombosis of the femoral veins, pleurisy, phlebitis 
of the veins of the leg, endocarditis and cystitis 
have also been observed. Sequelae have not de- 
finitely been known to occur. 

Up to the present only three authentic fatal cases 
have been described. In all of these paratyphoid 
bacilli have been isolated from the organs after 
death, but in no case was any characteristic lesion 
found. The appearances were in most cases those 
of an acute general infection. 

Studies undertaken to show the morphology, 
cultural characteristics, and behavior toward 
various media of the bacillus of paratyphoid fever 
bring out the characteristics distinctive of the 
paratyphoid bacilli "A" and "B." It is shown: 
(i) That there is a distinction between "A" and 
"B" paratyphoid bacilli. (2) That as regards the 
characteristics here alluded to paratyphoid "A" 
organisms are on the whole nearer bacillus coli than 
the "B" group. (3) That bacillus paratyphoid 
"B" is identical as regards its cultural character- 
istics with Gartner's bacillus. (4) That "A" and 
"B" paratyphoid bacilli are distinct both from the 
bacillus coli communis and the bacillus typhosus. 

Dr. Keith considers the serum reactions in cases of 
paratyphoid infections and their bearing on the serum 
test in typhoid fever. The chapter in which this 
portion of the subject is dealt with is both too 
long and too technical to be adequately treated in 
an editorial. The value of immune sera is pointed 
out (i) As a means of identifying bacilli quickly. 
(2) As a means of showing the more exact rela- 
tionship of bacilli to other members of a family or 
group. 

The author gives the following resum6 of the 
conclusions drawn from the investigations considered 
by him: (i) That there exists a disease which 
simulates the disease known as typhoid fever so 
closely that they can only be distinguished by 
bacteriological means. (2) That the disease is 
caused by an organism which exists in two varieties 
and which may be regarded as bacteriologically 
intermediate between the bacillus typhosus and the 
bacillus coli communis. (3) That the disease is on 
the whole mild and that the prognosis is good. (4) 



That the treatment of the disease is similar to that 
of typhoid fever. (5) That the disease spreads 
in the same manner as typhoid fever, a nd that the 
same hygenic and general measures should be taken 
in cases of this disease as are adopted in typhoid 
fever. (6) That in suspected typhoid-like cases 
a bacteriological examination is of the greatest 
importance both for diagnosis and prognosis and 
should be made wherever it is possible. (7) That 
up to the present the disease must be regarded as 
acute general infection in which no definite local 
lesion has been shown to exist. 

Paratyphoid fever is probably conveyed in the 
same manner as is typhoid fever. It is not markedly 
infectious. The incubation period is about fourteen 
days, the spots appearing from the twentieth to 
twenty-sixth day. Perhaps the most valuable de- 
ductions to be drawn from the investigations of para- 
typhoid fever is that experiments have tended to 
show that immune sera can be produced which have 
a protective power against lethal doses, not only of 
homologous organisms but also of organisms which 
are related, thereby indicating to some extent the 
possibility of a new line of treatment in cases of 
infectious diseases. 

Wright, as is well known, is of the opinion that 
typhoid fever can be warded off completely in some 
cases and in others rendered less severe by injections 
of dead cultures. Dr. Keith suggests that the 
indications given by the results of the experiments 
on animals with protective sera in the case of 
bacillus t3'phosus and allied organisms is but the 
initial stage of a new curative method of treatment. 
This matter, however, requires further elucidation 
before any large definite statements can be made 
regarding it. ' Nevertheless, it may be said that 
the prospect is hopeful. 



Tr.ichoma as an Epidemic and Maritime Disease. 

In the annual report of the Surgeon-General of 
the Public Health and Marine Hospital Service for 
the fiscal year 1903, recently issued, Passed Assistant 
Surgeon J. M. Eager has an article on the above 
subject. The writer points out that the trans- 
missibility and relation to shipping of trachoma 
are brought prominently before the observer in 
connection with the inspection of emigrant ships 
in Italy. In view of the contagiousness of tra- 
choma, the Italian Government now refxises to 
allow the embarkment of cases of active ophthal- 
mia on emigrant ships leaving Italy, either for 
South America, where there is no prohibition 
against the entrance of trachoma, or for the United 
States. The object of this ruling is to prevent the 
spread of the disease aboard ship. 

Dr. Eager reviews the history of trachoma from 
an epidemiological standpoint, and says that 
while it may be considered as a disease which, 
though known in ancient times to be contagious, 
was not noted to take on an epidemic character 
until recent centuries. Hippocrates, Galen, Plu- 
tarch of Cheronca, and Rhases, the famous Arabian 
physician of the ninth century, mention oph- 
thalmia as an eminently contagious malady. The 
Rabbi Moses, a great exponent of the doctrines of 
Galen, says in his aphorisms that to gaze steadily 
into the eyes of a trachomatous person is enough 
to make anyone's eyes water, and that continuous 
contact with sufferers from ophthalmia generally 
results in contracting the disease. 

The name trachoma was given to the affection 



6o 



MEDICAL RECORD. 



[July 9, 1904 



through the writings of Prospero Alpino, an Italian, 
who visited Africa in the sixteenth century for the 
purpose of studying Egyptian medicine. It was 
through the campaigns of Napoleon that trachoma 
became prevalent throughout Europe. All the 
armies engaged in those wars being more or less 
aflected by the disease. In 1820 Guille of Paris 
demonstrated the contagiousness of trachoma. 

The only record found in literature of trachoma 
as a maritime disease is that given by Guill6 
(Biblioth(:que ophthalmologique, Paris, 1820). The 
disease occurred on a slaveship, Le Rodeur, which 
on the voyage out was free from ophthalmia, but 
whose slaves when sixteen days from Guadeloupe 
exhibited signs of the malady, which soon spread 
in the most rapid manner. 

At the present time trachoma is notably endemic 
in Arabia, Egypt, Italy, Spain, Western Russia, 
Poland, Ireland, and South America. Exact sta- 
tistics as to the prevalence of trachoma in Italy are 
not available, but these are, in most instances, in- 
complete, and in others, owing to inherent disad- 
vantages, entirely indecisive. However, enough is 
known to show that the disease is very prevalent in 
many ports of Italy. Dispensary reports establish the 
fact that trachoma is greatly on the increase in that 
country, while Professor Fortunate states that in some 
of the maritime places of Sicily and Sardinia, from all 
available means of observation, it may almost be 
said that the entire population is trachomatous. 

Dr. Eager ends an instructive paper by saying 
that the statistics of the medical inspection made 
in Italy for the United States are of little value in 
estimating the prevalence of trachoma in Italy for 
the reason that the figures are distorted by the fact 
that often persons notably trachomatous do not 
attempt to take passage or are refused the same 
by the transportation companies prior to the day 
of sailing, and so do not appear at the regular med- 
ical visit. . . . Then, too, many persons, some 
not trachomatous, but fearing they may fall under 
suspicion, and others really victims of the disease, 
practise a sort of universe malingery at the time 
of the inspection. Adrenalin with cocaine hydro- 
chlorate is a favorite prescription for eyedrops. 
By its application, a blanching of the conjunctiva 
is brought about, a condition which, even in the 
absence of other evidence, is sufficient to put the 
person under observation until the disappearance 
of drug effects has rendered proper examination 
practicable. 



Food Preservatives. 
A committee has recently been sitting, taking 
evidence as to adulterations and the use of pre- 
servatives in food. It has been especially consider- 
ing the question of the use of preservatives in 
food. According to the New York Times. Dr. 
Frear, in discussing this contention, said that the 
testimony of the manufacturers had pretty generally 
been that such goods could not be packed with- 
out preservatives without a certain percentage of 
loss, but we must remember that the housewife 
who puts up her own catsup and preserves also 
suffers a percentage of loss. "The best opinion," 
Dr. Frear says, "seems to be against the use of 
preservatives as a general proposition as injurious, 
but, on the other hand, it is argued that the quantity 
used is so small as to be harmless in the product's 
in which they are most necessary. The manufac- 
turers seem to believe that it ought to be enough 
if all goods containing preservatives were plainly 
labeled, so that the consumer could see for himself, 
and take the responsibility for what he is taking 
into his stomach." 



It is expected that the Secretary of Agriculture 
will be able in a few months to draw up a set of 
standards which will define what is meant by purity 
in foods, and what constitute adulterations. The 
Medical Record has always taken the view that 
preservatives [should, as far as is possible be absent 
from foodstuffs. In fact, there is little doubt that 
in the large majority of cases articles of food re- 
quire no preservatives. By allowing the use of 
foreign matter in food, the thin edge of the wedge 
for all kinds of deception is allowed to enter. Un- 
doubtedly, if the use of preservatives is permitted 
at all, food so treated should be plainly labeled. 
The question of pure food is a momentotis matter, 
and one which directly affects the whole commun- 
ity. Ignorant persons must be protected against 
themselves, and the manufacturers must remember 
that it is not only their interests which are at 
stake but the welfare, to a greater or lesser extent, 
of the entire population of the country. Selfish 
interests cannot be allowed to prevail over the 
good of the many, and legislation should be strictly 
enforced which clearly defines the relative position 
of manufacturers and the general public with regard 
to food preservatives. 



The Medic.\l Library Movement in the United 
States. 

Standard books on medicine and surgery, and 
the latest works on these subjects, together with 
the most recent medical literature, are considered 
to be essential to the phj^sician of the present 
day. Without access to these the up-to-date 
Hiedical man feels to some extent lost, for he 
recognizes that it is necessary for him to keep 
abreast with the times and to know something 
of everything that is going on in the medical world 
everywhere. Thus the medical library has become 
an absolute need, and the main provider of medical 
and scientific pabulum to the practitioner. As a 
factor in medical education the library is of in- 
estimable value, in this respect equalling if not 
transcending any other means. 

Dr. Albert T. Huntington of Brooklyn, in the 
Medical Library and Historical Jonrital. for April, 
1904, writes on the medical library movement in 
the United States. The first one in this country 
was founded in 1760, but it is only within the past 
forty years that the great medical libraries of 
to-day have been built up, and only within the 
last decade that the medical library movement has 
become active and widespread. 

Dr. Huntington gives a list of the various medical 
libraries in the countrj', the date of their foundations, 
and the number of volumes contained in each. 
There are in the United States 215 of such insti- 
tutions, while the number of volumes in these is 
estimated at 1,023,295. 

The author points out that if we should assume 
that all the libraries in the list compiled by him are 
in an active state of existence and their resources 
readily available to the profession, two striking 
facts are very evident: First, that certain centers 
are oversupplied with medical libraries, and that 
the fusing of several distinct collections into one 
great library whose resources should be free to the 
whole profession could not be other than ad- 
vantageous to the best interests of all concerned. 
Second, that there are certain large sections of 
the countr}- which are utterly barren of adequate 
medical library resources. 

Dr. Huntington is of the opinion that there are 
two requisites for the establishment and perma- 
nent success of a medical library: First, a desire 
on the part of the local profession to have a library; 



July 9, 1904] 



MEDICAL RECORD. 



61 



second, the control of that library, wherever the 
books are housed, by the medical profession. 
Therefore, it is best, whenever practicable, that 
the library should be separate, and under the 
auspices of some general medical organization. 
The foregoing is undoubtedly good advice and 
should be followed as far as is possible. 

The medical library movement has evidently 
taken firm root in the United States, and from 
all apprearances will flourish in the future to a 
greater extent than at present. 



Nrlitii nf tV Wrrk. 

Change in the Examination for the Army Medical 
Service. — The examination of applicants for com- 
mission in the Medical Corps of the Army was mate- 
rially modified on July i. Immediate appointment 
of applicants after successful physical and profes- 
sional examination — the latter embracing all sub- 
jects of a medical education — will be discontinued, 
and hereafter applicants will be svjbjected to a pre- 
liminary examination and a final or qualifying 
examination, with a course of instruction at the 
Army Medical School in Washington intervening. 
The preliminary examination will consist of a rigid 
inquirj- into the physical qualifications of applicarts 
and written exammat'on in mathematics (arithme- 
tic, algebra, and plane geometry); geography; his- 
tory' (especially of the United States) ; Latin gram- 
mar, and reading of easy Latin prose ; English gram- 
mar, orthographv, composition; anatomj'; physiol- 
ogy; chemistry and physics; materia medica and 
therapeutics; normal histology. The subjects in 
general education above mentioned are an essertial 
part of the examination and cannot under any cir- 
cumstances be waived. The preliminary examina- 
tion will be conducted concurrently throughout the 
United States by boards of medical officers at most 
convenient points; the questions submitted to all 
applicants will be identical, thus assuring a thor- 
oughh- competitive feature, and all papers will be 
criticised and graded by an Army Medical Board in 
Washington. Applicants who attain a general aver- 
age of 80 per cent, and upward in this examination 
will be employed as contract surgeons and ordered 
to the Army Medical School for instruction as can- 
didates for admission to the Medical Corps of the 
Army ; if, however, a greater number of applicants 
attain the required average than can be accommo- 
dated at the school the requisite number will be 
selected according to relative standing in the exami- 
nation. 

The course of instruction at the Army Medical 
School will consist of lectures and practical work in 
subjects peculiarly appropriate to the duties which 
a med'cal officer is called upon to perform. While 
at this school the students will be held under mili- 
tary discipline, and character, habits, and general 
deportment will be closely observed. The final or 
qualifjnng examination will be held at the close of 
the school term, and wilt comprise the subjects taught 
in the school, together with the following professioral 
subjects not included in the preliminary examina- 
tion: Surgery, practice of medicine; diseases of 
women and children; obstetrics; hygiene; bacteriol- 
ogy, and pathology ; general aptitude will be marked 
from observation during the school term. A general 
average of 80 per cent, in this examination will be 
required as qiialifying for appointment, and candi- 
dates attaining the highest percentages will be 
selected for commission to the extent of the ex'sting 
vacancies in the Medical Department. Candidates 
who attain the requisite general average who fail to 
receive commissions will be given certificates of grad- 



uation at the school and will be preferred for appoint- 
ment as medical officers of volunteers or for employ- 
ment as contract surgeons; they will also be given 
opportunity to take the qualifying examination \\ ith 
the next succeeding class. 

It is not thought that, for the present at least, the 
number successfully passing the preliminary exami- 
nation will be greater than can be accommodated 
at the Army Medical School, nor that the number 
qualifying for appointment will exceed the number 
of vacancies. If, however, the class of candidates 
qualifying should be larger than is now thought, the 
young physicians who fail to receive commissions 
will not have wasted their time, as the course of 
instrviction at the school, while in a large measure 
specialized to Army needs, is such as will better fit 
them for other professional pursuits, and further- 
more they will have received a fair compensation 
while under instruction. 

Admission to the preliminary examination can be 
had only upon invitation from the Surgeon- General 
of the Army, issued after formal application to the 
Secretary of War for permission to appear for exami- 
nation. No applicant whose age exceeds thirty 
years will be permitted to take the examination ; 
this limit of age will be rigidly adhered to. Hospital 
training and practical experience are essential req- 
uisites, and an applicant will be expected to present 
evidence of one year's hospital experience or its 
equivalent (two years) in practice. The first pre- 
liminary examination under the amended regula- 
tions above referred to will be held about August i . 
1904; those desiring to enter the same should at 
once communicate with the Surgeon-General of the 
Army, Washington D. C, who will furnish all pos- 
sible information in regard thereto. 

New York State Hospital for Incipient Tuber- 
culosis. — This institution was opened on July i, 
at Ray Brook, Essex County, under the superin- 
tendence of Dr. John H. Pryor. The following 
information concerning the admission and main- 
tenance of patients is from the act establishing 
a State Hospital in the Adirondacks for the treat- 
ment of incipient pulmonary- tuberculosis. 

Free Patients. — The trustees of the hospital are 
hereby given power and authority to receive therein 
patients who have no ability to pay, but no person 
shall be admitted to the hospital who has not been 
a citizen of this State for at least one year preceding 
the date of application. Every person desiring 
free treatment in the hospital shall apply to the 
local authorities of his or her town, city, or county 
having charge of the relief of the poor, who shall 
thereupon issue a written request to the superin- 
tendent of said hospital for the admission and 
treatment of such person. This request must 
state in writing whether the person is able to pay 
for care and treatment while at the hospital. The 
requests will be filed by the superintendent in a 
book kept for that purpose in the order of their 
receipt by him. When the hospital is completed 
and ready for the treatment of patients, or when- 
ever thereafter there are vacancies caused b}^ death 
or removal, the superintendent shall issue a re- 
quest to an examining physician, in the same city 
or county, or, if there is no such examining phy- 
sician in the city or county, then the nearest exam- 
ining physician, for the examination by him of 
said patient. Upon the request of the superin- 
tendent the examining physician shall examine 
all persons applying for free admission and treat- 
ment in the institution, and determine whether 
such are suffering from incipient pulmonary tuber- 
culosis. No person shall be admitted as a patient 
in the institution without the certificate of one of 



62 



MEDICAL RECORD. 



[July 9, 1904 



the examining phj'sicians certifying that such ap- 
plicant is suffering from incipient pulmonary- 
tuberculosis. Admission to the hospital shall be 
made in the order in which the name of applicants 
shall appear upon the application book kept by 
the superintendent of the hospital, in so far as such 
applicants are subsequently certified by the 
examining physician to be suffering from incipient 
pulmonary tuberculosis. Everj- person who is 
unable to pay for care or treatment shall be trans- 
ported to and from the hospital at the expense of 
the local authorities. At least once in each month 
the superintendent of the hospital shall furnish 
to the comptroller a list countersigned by the treas- 
urer of the hospital of all the free patients in the 
hospital, together vith sufficient facts to enable 
the comptroller to collect from the proper local 
official having charge of the relief of the poor such 
sums as may be owing to the State for the exami- 
nation, care and treatment of the patients who 
have been received by the hospital and who are 
shown to be unable to pay for their care and treat- 
ment. The comptroller shall thereupon collect 
from the local official the sums due for the care and 
treatment of each such patient at a rate not ex- 
ceeding five dollars per week for each patient. 

Private Patients. — Applicants for admission to 
this institution who are able to pay for their care 
and treatment are not required to obtain a written 
request from the local avithorities having charge 
of the relief of the poor, but should apply in person 
to the superintendent, who will enter the name of 
the applicant in the book to be kept by him for 
that purpose, and when there is room in the hos- 
pital for the admission of the applicant without 
interfering with the preference in the selection of 
patients, which shall always be given to the in- 
digent, such patients shall be admitted to the hos- 
pital upon the certificate of one of the e.xamining 
physicians, which certificate shall be kept on file 
by the superintendent. The trustees shall have 
power and authority to fix the charges to be paid 
by patients who are able to pay for their care and 
treatment in the hospital or who have relatives, 
bound by law to support them, who are able to pay 
therefor. 

Examining Physicians. — In the Manual of the 
State Board of Charities for 1903, it is stated that 
the trustees of the New York State Hospital for 
the Treatment of Incipient Pulmonary Tubercu- 
losis will appoint in all the cities of the State rep- 
utable physicians, citizens of the State of New 
York, to examine all persons applying for admission 
to the hospital. There are to be not less than two 
nor more than four of such examining physicians 
appointed in cities of the first-class, and two each 
in cities of the second and third class. The exam- 
ining physicians must have been in the regular 
practice of their profession for at least five years, 
and must be skilled in the diagnosis and treatment 
of pulmonary diseases. Their fee for each patient 
examined will be three dollars. The law expressly 
provides that not more than one-half of all the 
physicians to be appointed under this section shall 
belong to the same school of medical practice. 
The examining physicians for New York City are 
Dr. H. M. Biggs and Dr. Egbert Le Fevre. Other 
examiners throughout the State are Dr. S. B. Ward 
of Albany, Dr. Eisner of Syracuse, and Dr. H. R. 
Hopkins of Buffalo. 

Examinations of the Public Health and Marine 
Hospital Service.— A board of officers will be 
convened to meet in Washington, D. C, Monday, 
October 3, 1904, for the purpose of examining 



candidates for admission to the grade of a.ssistant 
surgeon in the Public^Health and Marine Hospital 
Service. Candidates must be between twenty -two 
and thirty years of age, graduates of a reputable 
medical college, and must furnish testimonials from 
responsible persons as to their professional and 
moral character. The usual order of the examina- 
tion is (1) physical, (2) oral, (3) written, and (4) 
clinical. In addition to the physical examination, 
candidates are required to certify that they believe 
themselves free from any ailment which would 
disqualify them for service in any climate. The 
e.xaminations are chiefly in writing, and begin with 
a short autobiography of the candidate. The 
remainder of the written exercise consists in exam- 
ination on the various branches of medicine, sur- 
gery, and hj-giene. The oral examination includes 
subjects of preliminarj- education, history, literature, 
and natural sciences. The clinical examination is 
conducted at a hospital and, when practicable, 
candidates are required to perform surgical opera- 
tions on a cadaver. Successful candidates will be 
numbered according to their attainments on exam- 
ination, and will be commissioned in the same order 
as vacancies occur. Upon appointment the young 
officers are, as a rule, first assigned to duty at one 
of the large hospitals, as at Boston, New York, New 
Orleans, Chicago, or San Francisco. After five 
years' service, assistant surgeons are entitled to 
examination for promotion to the grade of passed 
assistant surgeon. Promotion to the grade of 
surgeon is made according to seniority, and after 
due examination as vacancies occur in that grade. 
Assistant surgeons receive sixteen hundred dollars; 
passed assistant surgeons, two thousand dollars, 
and surgeons, twenty-five hundred dollars a year. 
When quarters are not provided, commutation at 
the rate of thirty, forty, and fifty dollars a month, 
according to grade, is allowed. All grades above 
that of assistant surgeon receive longevity pay, 
ten per centum in addition to the regular salary 
for every five years' service up to forty per centum 
after twenty years' service. The tenure of office 
is permanent. Officers traveling under orders are 
allowed actual expenses. Further information may 
be obtained by addressing the Surgeon-General, 
Public Health and Marine Hospital Service, Wash- 
ington, D. C. 

The Sanitary Degradation of Santiago. — On Jul}- i 
the municipal government of Santiago de Cuba dis- 
charged forty sweepers of the street cleaning force 
and fifteen cartmen, alleging that the step was made 
necessary by lack of funds. The remainder of the 
force refused to work until they had been paid their 
wages for May and June. It is stated that the streets 
have beer in a filthy condition since the flood, and 
many families are moving to the country to escape the 
epidemic, which they fear may result from the neglect 
of all sanitary precautions. The local press bitterly 
criticises the Havana government for its failure to 
provide and carr\- out necessary sanitary measures, 
and is urging the foreign consuls to bring the situa- 
tion to the notice of their governments. 

Popular Tracts on the Prevention of Tuberculosis. 
— The Committee on Sanitation of the Central 
Federated Union and the Committee on the Preven- 
tion of Tuberculosis of the Charity Organization 
Society have published a pamphlet on the prevention 
and cure of pulmonary tuberculosis, which bears 
the title, "Don't Give Consumption to Others; 
Don't Let Others Give It to You." It describes a 
number of the sanitary safeguards, which tend to 
check the spread and progress of the disease. 
Copies of the pamphlet may be had in English, 



July 9. 1904] 



MEDICAL RECORD. 



63 



Yiddish, Bohemian, and German upon application 
to the Charity Organization Society, 105 East 
Twenty-second Street. 

Excess of Zeal on the Part of a State Medical 
Examiner. — The State Board of Medical Exam- 
iners of California secured, on June 18, the con- 
viction of another physician for«practising without 
a license, and the minimum fine of $100 was as- 
sessed. Following immediately upon this case, 
another action was brought for which the president 
of the board is being severely censured. A young 
physician, a graduate of the University of Basel, 
and recently a fellow at Johns Hopkins, arrived 
in the city shortly after the last regular session of 
the board. Recognizing that he could not engage 
lawfully in practice, he refrained from opening an 
office. In recognition of his capability, however, 
he was asked to serve as the assistant to one of the 
attending physicians of the city and county hos- 
pital. Even in this capacity, it is stated, he re- 
frained from writing prescriptions. His conduct, 
nevertheless, met with the disapproval of the presi- 
dent of the board, who regarded it as a violation 
of the law, and summoned him to his office. Fail- 
ing to arrive at a satisfactory understanding, he 
placed him in the custody of a police officer in wait- 
ing, and a trial followed on June 21 and 22. The 
police judge has withheld his decision, but stated 
that no fine will be imposed, in case of conviction, 
owing to the peculiar circumstances. From the fact 
that the cities of the Pacific coast are overrun by 
the worst of charlatans, who make of the tourists 
an easy pre}-, the action of the official who caused 
the arrest of a young man of ability who was only 
waiting for the opportunity to obtain legal recog- 
nition, has caused much comment. 

An Illegal Practitioner Fined. — A man, styling him- 
self a doctor 01 therapeutics, on the diploma of the 
Eastern College of Electrotherapeutics and Psycho- 
logic Medicine of Philadelphia, was recently convict- 
ed in Philadelphia of practising medicine illegally, 
and made to pay a fine of S200. This was the result 
of a suit instituted by the Pennsylvania State Board 
of Medical E.-vaminers. 

Health Department Changes. — Dr. Thomas Dar- 
lington, president of the Health Department, 
transferred all the assistant sanitary superintendents 
last week. He said it was "for the good of the 
service." Dr. Walter Bensall was sent from Man- 
hattan to Brooklyn, Dr. P. J. Murray from Brooklyn 
to Queens, Dr. Gerald Sheil from the Bronx to 
Manhattan. Dr. J. T. Sprague from Richmond to 
The Bronx, and Dr. J. P. Moore from Queens to 
Richmond. 

Dr. Emily Dunning, who was the first woman to 
be appointed an ambulance surgeon, has become, in 
the regular course of service, house surgeon of 
Gouverneur Hospital and began her duties on 
July I. 

Ambulance Accidents. — The third collision of a 
Bellevue Hospital ambulance with a Third Avenue 
electric' car occurred a few days ago. The surgeon 
in each instance was seriously injured, and two of 
them are now in the' hospital suffering from the 
results of their injuries. It would seem to be 
advisable for the drivers of ambulances to slow up 
when approaching car crossings, until they see that 
the coast is clear, even at the expense of losing a 
few seconds in responding to the call. 

The New Vienna General Hospital. — On June 
21, 1904, the Emperor of Austria laid the corner- 
stone of the new AUgemeines Krankenhaus. to 
take the place of the present famous building. 



The new hospital will in reality be a village of 
fifty buildings and will contain every device and 
appointment known to medical science. It is 
the aim of the directors of this gigantic hospital to 
make it the finest, best, and most completely 
equipped hospital in the world. It will be built 
upon one of the hills of Vienna, overlooking the 
present site, and the grounds will be much more 
beautiful than those of the present hospital. 

Dr. Charles F. Roberts, Sanitary Superintendent 
of the Health Department of this city, on July i 
received a medal from his associates commemorating 
thirty-six years of service in the department. Dr. 
Darlington presented the medal in the rooms of the 
Health Department. In thanking his friends. Dr. 
Roberts recalled the fact that thirty-six years ago 
the population of New York was 800,000 and the 
death rate 36 a thousand, while to-day, with a 
population of 3.800,000, the death rate is 19 a 
thousand. 

The Late Dr. Grant H. Richmeyer. — At a regular 
meeting of the Medico-Surgical Society, held Friday, 
May 20, 1904, the following resolutions were 
adopted : 

Whereas, The society has learned with deep 
regret of the death of Dr. Grant H. Richmeyer on 
the 2ist of April last. 

Resolved, That the profession as well as the 
society has lost a valued member, whose genial 
character as a man and ability as a physician was 
esteemed by all his associates, 

Rcsohcd, That a copy of these resolutions be 
transmitted to his family as an evidence of our 
respect and of our sincere sj'mpathy in their afflic- 
tion; and that they be published in two of the 
Medical journals of this city. Robert J. Devlin, 
J. D. Nagel, Henry Griswold, Committee. 

Obituary Notes. — Dr. Bry.\n Gilmore Wilh.\ms, 
late assistant physician to the Long Island State 
Hospital at Kings Park, died at sea on May 13. 
He was a graduate of Bellevue Hospital Medical 
College in the class of 1893. Dr. Williams was held 
in the highest esteem by his colleagues, both as a 
co-laborer and as a sincere friend. His sympathetic 
attention and genial good nature added much 
toward the betterment and for the happiness of the 
patients under his charge. At a stated meeting of 
the medical staff of the Long Island State Hospital, 
June 23, 1904, the folio wing resolutions were adopted: 

Resolved, That we learn with feelings of deepest 
sorrow of the death of our late associate, Dr. Bryan 
G. Williams, which occurred at sea May 13, 1904. 

Resolved, That we desire to express to the family 
our sincere sympathy in this hour of sad bereave- 
ment. 

Resolved, That a copy of these resolutions be 
sent to his relatives and for publication in the medi- 
cal journals, and filed with the records of this hos- 
pital. 

Dr. M.\RY E. P.\RTRiDGE of Bennington, Vt., 
was drowned in Lake Champlain, near Bennington, 
on June 29. She was a graduate of the New York 
Medical College and Hospital for Women in the 
class of 1884. 

Dr. Thom.\s Flint, a native of New Vineyard, 
Me., died on his ranch, near San Juan, Cal., 
Tune 19. in the eighty-first year of his age. He 
was a graduate of the Jefferson Medical College in 
the class of 1849. He had lived in California since 
1 85 1, was a member of the State Medical Society 
and of the American Medical Association, and had 
taken an active part in all public affairs, serving 
at one time in the capacity of State senator. 



64 



MEDICAL RECORD. 



[July 9, 1904 



(Harxtspaxiiinut. 

OUR LONDON LETTER. 

(From Our Special Correspondent.) 

HOSPIT.\L SUXD.W PYOPNEU.MOTHORA.X ELASTICITY OF 

AORTA A NURSING HOME COMPANY ANESTHETIZED 

CATS SIR OLIVER LODGE ON EDUCATED MEN WHAT IS 

BRANDY ? OBITUARY. 

London. June 17. 1004. 

Hospital Sunday has come and gone. The most striking 
event in it was the discourse of the Bishop of Stepney at 
St. Paul's Cathedral. He made it the opportvmity of 
reproving the rich and pleasure-loving people of the mt-trop- 
0I&. Into the season — which he described as the festival 
of wealth and pleasure — he described hospital Sunday as 
coming as a shadow of suffering "and in the name of the 
poor of awful London" crying aloud, "Give an account 
of thy stewardship." He declared the love of money was 
spreading without the least increase in the sense of stew- 
ardship, and quoted a distinguished diplomat, who, after 
many years abroad, said, "When I left London and went 
out of London society it was indeed exclusive and some- 
what selfish, but it was under some sort of control; I return 
to find it a rabble, devoted to the worship of money and 
what money can buy." The craving for pleasure has 
become a disease, said the bishop — a disease manifesting 
itself in a want of consideration for others that would 
never be possible in a healthy mind. He instanced ladies 
at the stalls of charitable bazaars with beautiful dresses 
not paid for, the unpaid bill meaning to the poor dress- 
maker, harrassed for want of capital, the loss of home and 
the support of aged parents or invalid sisters. To this 
indictment the bishop added, "I speak of what I know," 
and went on to declare that the disease was as ripe in the 
middle classes. There were some, he said, who talked of 
throwing the hospitals on the rates. "If that came to 
pass," he concluded, "the last tie which binds the wealth 
of London to the spirit of stewardship would be snapped " 
Something might certainly be said in reply to the bishop's 
heavy indictment, but it would not hurt the fashionable 
congregation, and the wealth of the city has always been 
ready to assist. 

On this occasion the collection at St. Paul's amounted 
to ^5,000, and there are many other churches which appear 
to have given in accordance with their means. It is too 
soon to say whether the collection will this year be larger 
than last, but it seems probable. 

Professor Finlay of Aberdeen read notes at our Clinical 
Society of a case of pyopneumothorax in a boy of seven- 
teen admitted into the Aberdeen Infirmary with tubercu- 
lous pneumothorax on the left side. Resection of ribs 
was practised on three occasions, and the lad was treated 
for many months in the open air on the balcony of the 
ward. He was enabled to resume his work as a gardener, 
but there was still a discharging sinus. The tuberculous 
process at the right ape.x, which was also present at first, 
was arrested, but the urine for some time has contained 
albumin, suggesting further operation. Professor Finlay 
mentioned another case similarly benefited and one which 
had not improved by evacuation of the pus. He thought 
radical treatment better than repeated tappings or leaving 
the fluid alone, especially in view of the modem treatment 
of tuberculosis. 

Dr. Parkinson said the late Dr. Fagge had had several 
cases of recovery without operation, and asked if it was 
desirable to resort to it for so slight a benefit. Dr. P. 
Kidd said we should not be too much influenced by the 
older methods; the chief difficulty was to determine the 
extent of the disease. 

The elasticity of the aorta has been the subject of care- 
ful research by Drs. Herringham and W. H. Wills, who 
have communicated their results to the Medico-Chirurgi- 
cal Society as a contribution to the study of arterial 
sclerosis. These are some of the conclusions; The 
width of the vessel increases with age as the result of 
internal pressure; the more it is dilated the less it can 
be further stretched; after stretching it returns to its 
orig^al volume; elasticity depends chiefly upon the 
tunica media and loss of it in changes in the same coat, 
and this coat increases in substance \vith age, due to 
connective or elastic tissue or both; the muscular tissue 
does not seem to vary. 

•Dr. Clifford AUbutt expressed general interest in the 
subject, and said his owni opinions were corroborated by 
the research that a large class of arterial disease was con- 
sequent on high blood pressure. 

Dr. Auld said that he and the late Professor Coats had 
found that in some cases the elastic laminae underwent 
granular degeneration confined to the smallest fibers. 
Such a change might account for lessened elasticity, and 
it would be reinforced by any increase of connective tissue 
which would interfere with the elastic fibers. 



Dr. Morrison thought there was some muscular hyper- 
trophy, and Dr. Finlay hoped the authors would extend 
their "researches to the arteries of patients affected with 
syphilis and alcoholics. 

Dr. Seymour Taylor suggested extending the research 
to arteries that are" naturally tortuous. He had thought 
that arteries were tortuous from being in movable tissues. 
The splenic might be compared with the radial. 

Sir D. Powell said widening of the aorta reached its 
greatest degree about the age of forty, just when the stress 
of life at full pressure begins to tell. CUnically loss of 
elasticity of the aorta does not seem to be connected with 
cardiac hypertrophy. 

A company is being promoted to provide a nursing 
home at moderate charges. The existing homes are so 
expensive that the middle classes can scarceh' afford to 
enter them. They are, too, mostly the appanages of par- 
ticular surgeons. "Nor is it only the fixed price per week 
that proves deterrent. The extras rival the most sump- 
tuous hotels, though without their luxurious appoint- 
ments. 

The new company has secured the option of a fine block 
of buildings in Mandeville Place, an excellent position for 
the ptirpose, close to several professional localities. The 
proposal is to charge £2 2S. per week for board, lodging, 
and nursing. No visiting staff is to be appointed. Pa- 
tients will arrange with their own medical men, will only 
be admitted on the recommendation of their usual attend- 
ants. There will be a house surgeon on the premises foi" 
emergencies and to carry out the treatment of patient's 
own doctors. 

Among the exhibits at the University Converzasione a 
loan collection of cats excited considerable attention. 
They were passing their time under chloroform. Dr. 
Waller, F.R.S., on the program, remarked that "the 
accidental deaths under chloroform used for surgical anaes- 
thesics are principally due to fluctuations in the chloro- 
form percentage. The cats exhibited are spending the 
evening under one per cent, of chloroform and air pumped 
into the bell-jar by a Dubois pump, which is occasionally 
turned to keep up the supply. The cats are to return 
intact to their homes." 

One lady visitor was overheard to say "what dreadful 
headachesthe poor things will have to-morrow." I com- 
mend the remark to the antivivisectionists. 

Sir Oliver Lodge has given offence in some quarters by 
remarking in a review that certain ideas cannot be made 
"so childishly simple as to be apprehended by the general 
average of so-called educated men in this country, whose 
sense-perceptions in the direction of great and compre- 
hensive ideas have not been developed." It is rather a 
hard saving, but I do not suppose he meant it to be offen- 
.sive, though his critics are not slow to retort that the atti- 
tude of scientific men is too often one of contempt for 
others, and is responsible for much of the indifference of 
ordinary educated persons to their work. One admits 
there is insufficient appreciation of science, but adds there 
is also a "very marked absence of those great expositors 
of science who have forced their discoveries and theories 
on the attention of the so-called educated men of their 
time." This Roland for an Oliver is not undeserved in 
the light of the proceedings of the late meeting of the 
International Association of Scientific Societies and Acad- 
emies, which at its first meeting resolved to exclude the 
press. 

What is brandy? That question meets us just now in 
many newspapers and circulars. It was started by a 
prosecution of a person for selling as such a liquid con- 
taining 60 per cent, of spirit not obtained from the grape. 
Analysts have usually been willing to certify as genuine 
any spirituous liquor of a certain alcohoHc strength, but 
now the origin of the alcohol is to be taken into account. 
The magistrate accepted the definition of the pharmaco- 
poeia. The medical value of brandy is thought by many 
to depend on the ethers, but others think it does not differ 
from whiskey or other spirits, and they attribute all the 
effects of all these liquors to the amount of alcohol in 
them. It can certainly be plausibly argued that the alco- 
hol must overshadow the small amount of ethers. In the 
Oliver-Sharpey lectures lately delivered by Dr. Oliver, he 
mentioned that the effect of alcohol on the blood pressure 
is modified by other constituents of wines, etc. The rnag- 
istrate's decision on the case cited has set the advertising 
wine and spirit dealers to work with circulars, etc. From 
the agents of one I have received no less than twelve cir- 
culars, besides as many letters. It seems an extravagant 
wav of advertising. 

Brigade-Surgeon W. F. Colliott, late of the Royal Army 
Medic"al Corps, died on the 8th inst., aged si.xty-five. He 
entered the armv in 1S62. had charge of the cholera camp 
in India in 1S67, served in the Afghan war 1S78-80, for 
which he held the medal. Retired in 1899. 

Surgeon-General W. Thorn, I. M. S., died in his eighty- 
fifth year on the 12th inst. He retired in 1S77. 



July 9. 1904] 



MEDICAL RECORD. 



65 



Richard J. Dcardcn, J. P., of Manchester, died on the 
nth, only forty-nine, from blood-poisoning following ex- 
tensive cellulitis contracted at a post-mortem, which he 
undertook for a friend, and which within a week brought 
him to his death. He took the M.R.C.S. in 1879 and became 
House Surgeon at the Royal Infirmary and soon after 
entered private practice. He was divisional surgeon to 
the Manchester Police. 



OUR VIENNA LETTER. 

(From Our Special Correspondent.) 

OBSTETRIC P.^RALYSIS COMBINED GR.^VES' DISE.\SE .\ND 

ADDISON'S DISEASE FUNCTION OF THE PARATHYROID 

GLANDS SIG.VIFICANCE OF BLOOD IN THE STOOLS 

EXSECTION OF THE TRACHEA FOR CANCER OF THE 

THYROID KOCHENEGG IN THE CHAIR OF SURGERY 

A CHAIR OF RADIOLOGY. 

ViENN.\, June 10. 1004. 
At a recent meeting of the Pediatric Society, Dr. Zappert 
presented a two-year-old child with bilateral obstetric 
paralysis. At the age of six months there was paralysis 
affecting the deltoid, biceps, supraspinatus, and prachialis 
anticus. The finger movements were free, but the arms 
hung powerless, were rotated inward, could not be raised, 
and movements of the elbow-joints were impossible. 
Under massage and faradization, the paralysis gradually 
disappeared, imtil at present there remain only an inward 
rotation and an atrophy of the deltoid. The case is 
worthy of note because a bilateral obstetric paralysis 
very rarely occurs. 

In the Society of Psychology and Neurology, Dr. 
Hirschl presented a case which gave the symptoms both 
of Graves' disease and of Addison's disease. The patient 
was a brewer, thirty-six years old, who had been ill since 
August, 1903. and who first came to the clinic in the follow- 
ing November. Tremor, excessive sweating, and diar- 
rhoea marked the onset. .'\t the beginning of October, 
the patient noticed exophthalmos, and complained also of 
palpitation. The most noticeable symptom was extreme 
emaciation. From the middle of August to the 23d of 
November his weight fell from 90 to 58 kilos (198 to 128 
pounds). Along with the emaciation, went a high grade of 
motor weakness and progressive excitability. At the 
beginning of October, bronzing of the skin began, which 
reached its height at the time of the man's first appearance 
at the clinic. JExamination then showed, on the one hand, 
loss of motor power, bronzing of the skin but with no 
pigmentation of the mouth, excitability and forgetfulness ; 
on the other, struma, exophthalmos with the three eye 
symptoms, palpitation, and tremor. His weight was 
58 kilos (12S pounds); blood pressure, according to the 
tonometer. 100; microscopical blood examination normal ; 
hsmoglobin, according to the von Fleischl haemoglo- 
binometer, 70 per cent.; and glycosuria. At the be- 
ginning he had vomited excessively, and later had had 
diarrhcea. There were no physical signs of tuberculosis in 
the patient, but his mother and first wife had died of 
tuberculosis. 

Dr. Pineles has made known some recent discoveries 
in regard to the physiologj' and pathology of the thyroid 
gland and the parathyroids. The fact that after opera- 
tions on the thyroid in which the parathyroids are left, 
no tetany ensues, while after total thyroid extirpation, 
including the parathyroids, tetany is the rule, makes 
the assumption natural that there is a causal relation 
between the removal of the parathyroids and the de- 
velopment of tetany. Experiments on animals.namely 
monkeys and cats, have confirmed this opinion. These 
experiments showed that total thyroid extirpation, 
or the removal of the parathyroids alone, is followed by 
tetany, while the removal of the thyroid, the para- 
thyroids being retained, leads indeed to cachexia, but 
not to tetany. The results of operations on man are 
also confirmatory. After extirpation of a tongue tumor 
which had developed from a thyroid displaced upward, 
tetany did not follow, because the parathyroids, de- 
rived from the third and fourth branchial clefts, re- 
mained, and were not extirpated. In like manner 
tetany occurs less often after resection of the isthmus 
than after that of both lobes, because the parathyroids 
in the capsules of the lobes remain. 

In the General Medical Society, Dr. A. Loebl spoke 
concerning a new way of detecting the presence of blood 
in the ffeces, and of its diagnostic significance. Loebl 
proved its presence in the following way: First, the stool 
was examined in its original condition for fat; if it con- 
tained much fat, this was next extracted with ether; 
the remainder, or the stool not rich in fat, was set aside 
with acetic acid vmtil it was of the consistency of thick 
soup, or, in the case of a hard stool, a little concentrated 
acid was added. To 3 c.c. of this mi.xture was added 
an equal quantity of ether, and the whole allowed to stand 
for twentv-four hours. The extract was then di\-ided 



in two parts of 3 c.c. each; to the first was added freshly 
prepared tincture of guaiacum (a solution of guaiacum in 
ether), to the second, a solution of Barbadoes aloes in 
60 per cent, alcohol, and, finally, to each, peroxide of 
hydrogen. After a minute, the" portion with the tinc- 
ture of guaiacum becomes blue, the color disappearing 
after about fifteen minutes; in the second portion, the 
color appears later, but is permanent. Dr. Loebl has, 
by this method, examined the stools of 115 patients. 
The stools of twenty patients with tuberculosis of the 
lungs, who came to autopsy, were examined during life 
for the presence of tubercle bacilli and tor blood; nine 
cases showed ulcers of the intestine at autopsy, and of 
these, six showed tubercle bacilli and blood in the faeces 
during life, and three either one or the other: of the 
remaining eleven cases, examination had shown tubercle 
bacilli in seven, and neither bacilli nor blood in four. 

The presence of tubercle bacilli and blood in the fjeces 
is diagnostic of intestinal tuberculosis. In the case of a 
patient who suffered from gastric ulcer during the attacks 
of epigrastric pain, blood was continually found in the 
stools, and because of the persistence of this symptom, 
the ulcer was closed. The operation confirmed the diag- 
nosis. In typhoid fever, by the above method, slight 
bleeding could be detected, and, by the adoption of ade- 
quate measures, a greater hemorrhage could be stopped 
Further, blood has been found in the faeces in cas.s 
of intestinal parasites, tetany from autointoxication, 
and in two cases of cholelithiasis. Prof. Arthur Schiff 
stated in the discussion which followed that, according 
to the investigations of Boas and Hartmann, concerning 
the appearance of blood in the faeces, a prescribed diet 
must be adhered to. Otherwise blood from flesh food 
might be mistaken for hemoiThage from the intestine. 
Schiff asked for further information in regard to the pres- 
ence of blood in cases of tetan}- and cholelithiasis. Loebl 
answered that through very recently published in- 
vestigations the fact has been established that no blood 
is detected in the faeces after the eating of even very large 
quantities of cooked meat. Many of the patients ex- 
amined by him were, however, on a milk diet. On the 
other hand, after the use of the modem preparations of 
iron, blood is found in the faces, while this is not the case 
after the use of the official preparations. Blood in the 
stools of patients suffering from tetany comes from small 
hemorrhages following erosions, and is dependent on 
the accompanying catarrh. In cholelithiasis, the vul- 
nerability of the vessels is well known, and hemorrhage 
readily occurs. 

In the Society of Physicians, Professor von Eiselberg 
presented a patient who had been operated on for carci- 
noma of the thyroid, the operation including circular re- 
section of the trachea, followed by suture. The defect 
on the anterior wall of the trachea after the sloughing 
of the suture was covered by a flap of periosteum taken 
from the sternum. 

In 1898 a man, forty-four years old, having had trouble 
with his neck since his eighth year, was operated on at the 
Albert clinic for colloid struma. In 1900 the goiter 
returned, and increasing dyspncea drove the patient, m 
1902, to the Schrotter clinic, where tracheotomy was 
done. Through examination of an excised portion, 
diagnosis of adenocarcinoma of the thyroid was made. 
At first there was improvement, then the carcinoma in- 
creased in size through the trachea to the level of the 
fistula, when again extreme dyspnoea appeared. In 
January, 1904, tiie patient was admitted to the surgical 
clinic, and a large, hard, swollen thyroid was found, 
holding the trachea in its grasp. On January 11, 1904, 
Professor von Eiselberg undertook the extirpation of the 
tumor, for which it was necessary to resect 4 cm. of 
the trachea. Circular suture followed, after the in- 
sertion of a cannula. The stitches sloughed in the 
anterior half, and the defect was first covered provision- 
ally with a celluloid plate, and afterward with a flap of 
peinosteum from the sternum. This required two sit- 
tings, the first, Februarj- 19, and the second, March 5. 
A small endolarvngeal "mass of granulation tissue was 
aftersvard removed at the Schrotter clinic. Thus, 
through combination of the ideal methods, resection 
and suture, a good result was obtained. 

On May 13 Professor Hochenegg took charge of the 
Gussenbauer surgical clinic, which has won so high a 
reputation through his predecessor. Billroth. Hochenegg, 
who, as a pupil of Professor Albert stands in known 
opposition to the teachings of Billroth, at his inaugura- 
tion for which had gathered all the surgeons and almost 
the whole Vienna faculty, honoring his predecessor, 
called to mind and commended the service he had done 
to surgery. Hochenegg's address related to the treat- 
ment and transmission of carcinomata, the topic which 
up to the present time has formed a large part of the study 
of this clinic. 

Another event of this month was the establishment of a 



66 



MEDICAL RECORD. 



[July 9, 1904 



1 



chair of radiology, the first on this continent. It is 
occupied by Dr. Kienbock, Dr. Freund. and Dr. Holz- 
knecht, and their appointments were confirmed by the 
Emperor. All three have worked as pioneers in Austria, 
on the subject of radiology, and it remains now to be 
seen into what this yoimgest branch of our science will 
develop. 

THE PRESENT STATUS OF THE SURGICAL 
TREATMENT OF CHRONIC BRIGHT'S 
DISEASE. 

To THE Editor of the Medical Record: 
Sir: In your issue of July 2, 1904, appears a letter from 
Dr. Edebohls, bearing upon my article, "The Present 
Status of the Surgical Treatment of Chronic Bright's 
Disease." I hesitated to answer this communication, 
the tone of which warrants the belief that the writer 
considered my contribution to this interesting subject 
as a criticism of his views and practices, while in reality 
its prime and sole object was to develop and establish the 
indications for, and the limitations of, the rational em- 
ployment of surgical therapy in cases of chronic nephritis. 
Dr. Edebohls emphatically states in his letter that 
his patient, Mrs. C. B., whose history I quoted in ab- 
stract in my paper, suffered from chronic parenchymatous 
nephritis, upon which a bilateral py clone phr His with miliary 
abscesses was engrafted, whereas I claimed that the kid- 
neys of this patient presented simply the lesions of a 
baeterial (or septic) -nephritis. 

Here are the pathologist's reports (page 967): "Right 
Kidney. — The large right kidney, riddled with innimiorable 
abscesses and with its pelvis filled with pus, showed, on 
microscopical examination, typical, histological char- 
acteristics of multiple abscesses. In the abscess areas 
there was found a thick bacillus corresponding morpho- 
logically to a species of the proteus, a class frequently re- 
sponsible for suppurative nephritis." Left Kidney. — 
There is no description of its gross appearance, but micro- 
scopical examination of the small piece of renal tissue re- 
moved from the kidney showed "decided histological evi- 
dence of multiple foci of nephritis of infectious (septic) type. 
As far as was possible to determine from the minute size 
of the cortical issue received, these foci were confined to the 
areas corresponding to terminal arteries and consequently 
had a wedge-shaped outline. In the diseased areas, the 
tubules presented granular and partially disintegrated 
epithelia, often detached from the mernbrana propria, 
and the lumina were not infrequently occluded by polj'- 
nuclear leucocytes (pus), fragmented epithelia' blood 
cells, and amorphous detritus. Some tubules were filled 
with dense hj-aline material (casts)." 

Where in these reports are the gross or microscopical 
evidences of chronic parenchymatous nephritis? Was I 
not right in my statement that these kidneys showed only 
the lesions of infectious (bacterial) nephritis? Our 
criterion in these cases is the pathological findings, and 
from these I drew my conclusions. Upon what evidences 
does Dr. Edebohls base his diagnosis of chronic paren- 
chymatous nephritis in addition to the infectious (bac- 
terial) nephritis? 

As to my statement that Mrs. C. B. "finally [suc- 
cumbed to the disease," I regret exceedingly that in 
arranging the material which was to be employed in my 
paper, this patient was recorded as having died. Such 
errors are bound to occur in handling so large a number 
of cases from the hterature, especially when the patient's 
final outcome must be sought for in different numbers of 
the medical papers. But while this patient's recovery 
is most happy for herself and friends, and most important 
for Dr. Edebohls' statistics, it has no significance at all as 
regards the arguments in my paper. I consider this 
cascasoneof bacterial nephritis, and concerning the value 
of surgical therapy in this type of chronic nephritis, I 
stated on page 996: "The bacterial nephritides of chronic 
character are at times favorably influenced bv operation." 
Of Rovsing's eight cases, seven were cured "and one was 
improved. 

It is thus seen that recovery in the bacterial form of 
chronic nephritis has been the rule, and I am most happy 
to learn from the doctor that his patient is so far doing 
well, and I regret the error which occurred in the tabula- 
tion. 

From the above it is evident that the validitv of mv 
deductions and conclusions are not nullified bv'the in- 
correctness of the premises upon which thev are based 
(letter, page 26), but rather show that the studv of this 
case before the operation upon the second kidnev was 
incomplete, for a culture of the urine of the left or"an drawn 
by aseptic ureteral catheterization would probablv have 
revealed the infecting organism and so have led to a correct 
ante-operative diagnosis. 

The incongruity" of the criticism of Dr. Edebohls con- 
cerning avoidable errors on my part will appear at once 



to him who reads the doctor's writings and reports of 
cases and fails to find therein any mention of a system- 
atic practice to determine by aseptic ureteral catheteriza- 
tion and culture from the urine obtained in this way, the 
nature and causation of a chronic nephritis, and who 
misses in his publications the routine practice of ex- 
perienced kidney surgeons of determining the combined 
and individual functional sufficiency or insufficiency of 
the kidneys by the absolute scientific means which ureteral 
catheterization and cryoscopy have put at our disposal, 
before proceeding to operation upon these organs. 

A. A. Berg, M.D. 
523 M.tDisoN Avenue. 



Boston .McJi<:ai and Surgiiai Journal, June 30, 1904. 

Anomalies of Thyroid Secretion. — Frederick C. Shat- 
tuck gi\es a most interesting paper on the evolution of 
our present knowledge of thyroid function, reviewing 
step by step the advances that have been made in the 
knowledge and treatinent of thyroid affections in recent 
years. Whether the action of the thyroid and parathy- 
roids is antagonistic, complemental, or unrelated, we 
do not yet know. But the evidence so far does not seem 
to indicate a vital causal connection between the parathy- 
roids and Graves' disease. The whole treatment of 
myxcedcma is practically comprised in the administra- 
tion of thyroid extract. It is safer to begin with moder- 
ate doses, from 3 to 5 grains, twice a day for an adult, 
increasing the dose in size, frequency, or both, as the 
tolerance of the patient is developed. The treatment 
of Graves' disease has long been unsatisfactory' at the 
best. The diet should consist mainly of fats, "starches, 
and sugars, with great moderation in or abstention from 
highly nitrogenous food. Rest and quiet are most ad- 
visable. A cool suminer resort is verj- important. The 
bowels should be carefully looked after. The bowels 
are apt to be either constipated or relaxed. Diarrhcea 
may be treated by some form of bismuth. Calomel, 
once or twice a week, has been used with success in cases 
of constipation. Neutral bromide of quinine has brought 
about normal defecation both in cases of diarrhoea and 
of constipation. This drug, the writer has found more 
helpful than any other he has ever used. The toleration 
of quinine in Graves' disease is remarkable, and is seem- 
ingly proportional to the severity of the symptoms. If 
these measures are not foUow^ed by distinct improvement 
operation is to be seriously considered in severe cases. 

Journal of the .American Medical .Association. July 2,1904. 

Dysentery; A Report of Several Cases in Which Bacillus 
Dysenteriae (Shiga) Was Found in Washington, D. C. — 
Louise Taylor-Jones concludes that Washington, D. C, is 
incKided in the geographical distribution of B. dysentcrice 
(Shiga). The Shiga bacillus, both alkaline (Shiga) and 
acid (Floxner) types, is found in that city both in adults and 
children suffering from dysentery. An alkaline type 
found in one case was a slight \'ariation from the type, in 
that in three days in glucose agar, not first made sugar- 
free, the bacillus produces a slight amount of gas, whereas 
no gas is produced with the sugar-free glucose agar. None 
of the other Sliiga bacilli at hand produced gas in this 
same Tiiedium. 

Lumbar Abscess: Report of Six Cases Treated by As- 
piration and Injection of lodoform-Glycerin Emulsion. — 
Alfred Irving Ludlow made this clinical report and sum- 
marized as follows: (i) Four cases gave a family history of 
tuberculosis. (2) Five cases occurred in females whose 
ages ranged from seven to thirty-nine years and one case 
in a male twenty-five years old. (3) Two patients gave 
a history of injury to the back. (4) In three cases two 
aspirations were made, in one case three, in another four, 
and in another ten. (5) The urine from four cases out of 
six gave a reaction for iodin the next day after the as- 
piration. This reaction persisted only for two or three 
days, except in one case in which it persisted for two 
weeks. (6) Slight mental depression was noticed in two 
cases. (7) As a general rule, there was an elevation of 
temperature from two to four degrees following each 
aspiration. (S) The cultures were sterile in every case 
except one, in which Bacillus proteus vulgar isvca.sohta.\ned. 
(9) In all the si.x cases there has been no indication of 
return of the abscess after a period of five years in one 
case, three years in another and two years in a third, 
while in the remaining three, one year or less has elapsed 
since the last aspiration. There was a marked improve- 
ment in the general health of every patient. 

Medical Xeu-s, July 2. 1QC4. 
Diagnosis and Treatment of Internal Hemorrhoids. — 
H. A. Bray coricludes that (i) In the treatment of internal 
hemorrhoids, it is important, in the first place, to de- 



July y, 1904] 



MEDICAL RECORD. 



67 



termine whether the disease is primary or secondary to 
some affection of the pelvic organs. (2) In the first stage 
of hemorrhoidal disease no operative treatment is in- 
dicated. (3) The tnie value of the non-operative treat- 
ment is frequently underestimated in the second stage 
of hemorrhoidal disease. (4) None but operative treat- 
ment should be resorted to in the third stage of hemor- 
rhoidal disease. 

Primary Myokymia; with Report of a Case. — Robert M. 
Daley defines myokymia as a disorder characterized by 
fibrillary and wave-like contractions of the individual 
fibers of various muscles of the body without locomotor 
eflect. Usually it appears as a minor symptom, in 
diseases of to.xic origin, such as lead and mercurial poison- 
ing. It is also seen in neurasthenia and in sciatica. It 
may occur as the only morbid condition. Of the cases 
previously reported, all save two, ha\-e been among the 
laboring classes. All of these cases were males, the ages 
running from twenty-one to seventy-one years. In two, 
the legs only were affected; in the remainder, the legs and 
arms or legs and entire muscular system, excepting in one 
instance, the hands, and in another, the face and neck. 
None show atrophy of the muscles or much disturbance of 
the general health. Nearly all complain of general pains, 
indefinite in character, and also of becoming easily tired. 
Four cases were cured and improved by rest, galvanism, 
and warm baths. Of the patholo.gy nothing is known. 
The writer reports a case of this nature. 

A Consideration of the Question of Drainage in Cases of 
Acute Appendicitis with Spreading Peritonitis. — Lucius 
Wales Hotchkiss believes that he has amply demonstrated 
the great value of the smaller incisions, of the location and 
removal of the appendi.x largely by the sense of touch, 
which does away with over much exposure and handling 
of the intestines and of the free irrigation of the peritoneum 
with hot normal salt solution, depending upon this rather 
than drainage and the removal of the diseased appendix 
in every possible case. This practice is a radical depar- 
ture from the method formerly employed. The power of 
the peritoneum to deal with infection is marvelous. In 
acute progressive appendicitis, nature strives to wall off 
the diseased organ by a barrier of plastic exudate and 
throws out a powerful second line of defense against gen- 
eral infection by bringing about marked hyperleucocytosis. 
In the case of the gangrenous appendix, however, the 
task is, as a rule, too much for the natural physiological 
processes to accomplish unaided. The first thing to do is 
to remove the focus of infection, the appendix, and to do 
it so as not to cripple the inherent power of the peri- 
toneum to deal with such toxic products as must neces- 
sarily be left behind. The writer states that during the 
past few years he has grown to rely almost wholly upon 
the flushing of the peritoneal cavitj' with hot normal salt 
solution, rather than upon any method of external drain- 
age. The writer believes that the drain has practically 
been eliminated as a factor of any importance in the 
treatment of spreading peritonitis, excepting so far as it 
acts as a drain for the e.xtemal wound, which, in most of 
these cases is an infected wound and heals by granulation. 
The writer agrees with Clark and Norris in their conclu- 
sions that the use of salt infusions does not increase, but 
minimized the danger of pyogenic infection ; and in ad- 
dition to the reduction of mortality, the convalescence of 
the patient is rendered infinitely more comfortable and 
satisfactory through the reduction of thirst, the increase 
in the urinary excretion, and the minimizing of vesical 
irritation. 

Xew York Medical Journal, July 2, 1904. 

X-ray Therapeutics. — G. H. Stover relates fifty- 
one cases which in part indicated the main features 
of the work being done by the ;i;-ray. Lupus er^-the- 
matosus is more slowly amendable to treatment by the 
x-ray than are other forms of lupus. So uniform has 
been his success in the treatment of epithelioma that 
he believes the .t:-ray to be a specific for this condition. 
In carcinoma the results have not been so gratifying. 
His results in the treatment of bone tuberculosis has 
been gratifying. In certain diseased conditions the 
effect of the .v-ray was very satisfactory, even brilliant, 
yet for a long time to come great caiition should charac- 
terize our utterances to patients. He regretted the 
rash manner in which many who were totally unfitted 
were pushing into i-ray work. He believed that after 
a while there was going to be a reaction against the 
x-Ta.y as a therapeutic measure, and he hoped the 
pendulum would not swing too far, casting undeserved 
discredit on a therapeutic agent that has established 
a rightful place for itself. 

Hermann Brehmer, and the Semi-centennial Cele- 
bration of Brehmer's Sanatorium for the Treatment of 
Consumptives (July 2, 1854- Ju'y 2, 1904) — S. A. Knopf 
believes that a fitting tribute to the fotmder of the 



first sanatorium in the world for the exclusive treat- 
ment of patients afflicted with pulmonary tuberculosis 
and the best known promulgator of modem phthisio- 
therapy may well be paid on this occasion from this 
side of the Atlantic. Hermann Brehmer was bom 
in Kurtsch, Province of Silesia, Pmssia, August 4, 1826. 
He attended the Elisabeth Gymnasium in Breslau, 
and after receiving his classical degree went to the Vni- 
versities of Breslau and Berlin, studying natural phil- 
osophy and mathematics. He was so attracted by 
the lectures of Johannes Miller, the great physiologist, 
that he decided to study medicine instead of mathe- 
matics. He began to practise in the little village of 
Goerbersdorf which, at that time, had no more than 
900 inhabitants. Owing to *he intervention of Hum- 
boldt and Schoenlein, he received concession from the 
government to build his sanatorium. It had a small 
beginning, but its success was marvelous, and to-day 
it is the largest private institution of its kind in the 
world, and can accommodate about 300 patients. Breh- 
mer died December 12, 1889, when the sanatorium 
movement was hardly in its infancy. At the time of 
his death there were three sanatoria in Germany, while 
now there are hundreds. In the United States there 
are now 135 institutions already in operation or pro- 
jected. 

The Results of X-ray Treatment. — Samuel Beres- 
ford Childs concludes from his own experience and that 
reported by others: First: The therapeutic field of 
greatest usefulness of the a--ray is with superficial epi- 
theliomata, rodent ulcer, and lupus vulgaris, when the 
area involved is conspicuous, as on the face or neck, 
and where a cosmetic result is particularly to be desired. 
Second: Healing by the i'-ray leaves the smallest 
and least perceptible scar; for, when properly applied. 
it destroys onlv diseased tissue, and particularly com- 
mends itself for use in those localities where it is un- 
desirable to sacrifice the surrounding tissues. Third: 
The .v-ray is very efficacious in many obstinate cases, 
which have resisted the ordinary methods of treatment, 
such as acne rosacea, chronic localized patches of eczerna 
and psoriasis, lupus erythematosus, and kindred skin 
diseases. Fourth: The' results in tuberculosis glands, 
when no suppvirating focus is present, are encouragmg 
and the enlarged mass of glands in Hodgkin's disease ap- 
pear to be susceptible to the treatment. Fifth: The 
.i;-ray should not be employed in any operable, deep, 
malignant growth, with two exceptions: First: as 
pointed out by Coley, where a surgical operation would 
sacrifice an extremity, and even in this case the value 
of the jc-ray is uncertain, and is determined by a few 
weeks' trial. Second, as mentioned by Pusey, with a 
view to limiting the operation by checking the growth 
when immediate operation is inadvisable. Sixth: The 
.r-ray mav be of service even in inoperable malignsnt 
growths, by relieving pain, diminishing discharges, and 
lessening their offensiveness, and in many cases life 
may be prolonged in comparative comfort for a con- 
siderable period of time. Furthermore, from these ap- 
parently hopeless cases a number of remarkable im- 
provements and a few recoveries have been reported. 
Seventh: The .-r-ray should be used as a prophylactic 
against return after "all operations for the removal of 
deep malignant growths. Eighth: The area of ex- 
posure should be wide, and the intensity and quality 
of the rays should be adapted to each case. 
Amcru-an Mcdu~im. July 2, 1904 
Measurements of Blood-pressure in Fevers Before, 
During, and After the Administration of Strychnine. — 
Richard C. Cabot declares that among those cases studied 
were 31 of typhoid fever, 4 of pneumonia, and 1 5 others 
with a variety of diagnosis. In 3 2 cases the strychnine was 
given bv mouth, and in iS subcutaneously. The total 
daily dose was usually '/i grain. The measurements 
were taken with Stanton's modification of the Riva- 
Rocci instrument. The observations extended over 
about eight months, and include over 5,000 measurements. 
The total result is negative. The writer cannot see that 
strychnine exerts any influence upon the blood-pressure 
in febrile cases, when given in the manner and dose as 
mentioned. In the 24 hours following the administra- 
tion of the dmg there was a rise of 5 mm, or more of 
pressure in 16 cases, a fall in 17 cases, and no change in 
24. The average pressure in the 50 cases that received a 
daily dose of strychnine was no greater than in 18 control 
cases without any drug. While strychnine and whiskey 
seemed to be entirely without influence upon the blood- 
pressures, the sight "of the dinner tray or the prospect 
of getting- up produced a most obvious, though transient, 
rise in the pressure. The writer concludes that in the 
dosage used, strvchnine does not raise or in anyway effect 
the maximum or minimum blood-pressure so far as can 
be determined bj^ the instrument employed. 



68 



MEDICAL RECORD. 



[July 9, 1904 



Tuberculosis As It Affects the Skin. — M. B. Hartzell 
declares that the most frequent form of skin disease 
due to the tubercle bacillus is lupus vulgaris. It is 
possible to demonstrate the presence of bacillus tuber- 
culosis in lupus tissue, but this organism is scanty in 
numbers. This disease may also effect the nasal, buccal, 
laryngeal, and vaginal mucous membranes. "Tubercu- 
losis verrucosa cutis" is closely related to lupus vulgaris 
in some of its features. Identical with verrucose tuber- 
culosis is the so-called anatomic wart, verruca necro- 
genica. One of the earliest recognized forms of tuber- 
culous affections of the skin is the tuberculous ulcer, 
known also as miliary tuberculosis of the skin. It is 
usually found about the orifices of the body, and is in 
the great majority of cases secondary to tuberculosis 
of other organs. It may, however, occur upon other 
parts, and it may occur as a primary lesion, and be fol- 
lowed by visceral tuberculosis. Scrofula is but a mani- 
festation of tuberculosis. It gives rise to a n\imber of 
skin lesions, usually ulcerative, to which the name scrof- 
uloderms has been given. The commonest form of 
scrofuloderm is the chronic ulcer which occurs so often 
in connection with tuberculous adenitis, especially in 
the region of the neck. In all of these affections, the 
presence of bacillus tuberculosis has been demonstrated 
^•ith more or less certainty. Another class of eruptions 
is seen in individuals who either in themselves or m the 
memljers of their families show a more or less clear his- 
tory of tuberculosis, but in which all efforts to find the 
tuberculous organism have failed, although the tissue 
changes are such as are present in tuberculous disease. 
The constitutional treatment of tuberculosis of the skin 
differs in no respect from that of tuberculosis of other 
tissues. 

The More Remote Consequences of Infectious Bile. 

— John B. Deaver calls special attention to these three 
conditions — pancreatitis, biliary cirrhosis, and adhesions 
of the gall-bladder to various of the surrounding vis- 
cera. Seventeen cases of acute pancreatitis ha\-e been 
reported, eleven of which were accompanied by calculi 
in the biliary tract. A considerable number of cases 
do occur, however, in which gallstones are absent, and 
should be carefully studied, for gallstones do not always 
induce acute pancreatitis. Especially must the infer- 
ence of microorganisms be considered as causative fac- 
tors in obstructing the pancreatic ducts. Bacteria may 
not only infect the retained secretion, but may also by 
direct continuity ascend from an existing gastrointes- 
tinal cataiTh. Chronic pancreatitis is also often due to 
sorne obstruction of the duct of the pancreas by gallstones. 
This is especially striking when the biliary' calculus is 
large, and so situated that the duct of Wirsuiig is occluded 
without the entrance of the bile into the pancreas. The 
diagnosis of pancreatitis is often very difficult. In gen- 
eral, when an individual from whom the history of a 
previous gallstone colic may or may not be elicited, is 
suddenly seized with severe epigastric pain, nausea, 
vomiting, rapid pulse, dyspnoea, and cyanosis, fol- 
lowed by a rapid loss of strength, the "diagnosis is 
acut« pancreatitis. The early symptoms strongly 
resernble those of intestinal o'bstruction, and the ex- 
haustion and collapse are often so severe as to induce 
death within forty-eight hours. The pain is colicky 
in character. Chronic pancreatitis, due to gallstones, is 
often hard to recognize. It is only by grouping both 
the clinical and the laboratory findings that the disease 
of the pancreas may be accurately and satisfactorily 
studied. As to biliary cirrhosis, the writer states that 
in the great majority of common-duct obstruction cases 
for which he has operated, a bacteriologic in\-estigation 
of the bile has revealed the presence of some microorgan- 
isms, the colon bacillus, the typhoid bacillus, the staphy- 
lococcus, or the streptococcus." He belie\es that as com- 
plete bile stasis rarely occurs in common-duct obstruc- 
tion, infection must exert a positive influence in the 
cirrhosis. Adhesion of the gall-bladder or ducts to sur- 
rounding viscera will follow nearly all severe inflammations 
of the gall-bladder from a pericholecystitis and embar- 
rass the functions of the contiguous organs involved by 
the adhesions. The typhoid bacillus is a most fertile 
factor in the production of acute or chronic biliary tract 
disease, or in the causation of gallstones. But the first 
place in the r61e of gallstone producer must be credited 
to the colon bacillus. The entrance of bacteria into the 
biliary tract is possible by three wavs : Thev may ascend 
the bile ducts from the duodenum," are dep"osited by the 
general circulation, or reach the ducts and gall-bladder 
by means of the portal vein. 

The Lancet, June 25, 1004. 
Notes on Three Cases of Intestinal Obstruction. — G. 
Reinhardt Anderson makes a record of three cases of 



intestinal obstruction which were instructive as the)' illus- 
trated the necessity of caution before expressing an opin- 
ion on conditions leading to the obstruction. The first 
case was one with an vmsuspected obturator hernia occur- 
ring in an elderly woman. In the second the small intes- 
tines were so matted together that obstruction, which had 
been incomplete for some time, became suddenly complete, 
and for this condition lateral anastomosis had to be per- 
formed. The last case was one of chronic obstruction due 
to inflammatory exudation in the pelvis, necessitating a 
temporary colotomy for its relief. 

A Case of Mania from Traumatic Meningitis; Recovery 
after Trephining. — Charles Brook reports the case of a 
man. twenty years old. who struck his forehead violentl)' 
on the bottom when diving. He was not rendered uncon- 
scious, but went home complaining a little of his head. 
His manner changed from that day and he became irrita- 
ble and excitable and within one month had paroxysms 
of violence. Six months later he was placed in an asylum. 
Six weeks later Dr. Brooks saw him and found a distinct 
swelling on the right frontal bone, rather red and some- 
what tender. Trephining was advised and performed. 
The bone was rather thin and very hard and white, with 
no diploe. The dura was opened and three ounces of clear 
serum let out. The wound healed perfectly. Never from 
the time the patient reco\ered consciousness has he shown 
the slightest sign of mental disturbance. 

The Prophylactic Use of Morphine in Cases of Severe 
Cerebral Injury. — J. A MacDougall, in 1890, when he read 
a paper on "Meningitis," by Dr. Barr of Liverpool, real- 
ized how freely morphine might be given in this disease, 
how excellent were the results attendant upon its employ- 
ment, and how in all probability its beneficial action was 
brought about largely through its effect upon the vascular 
and ner\-ous systems, inducing that condition of rest. 
Further and natural reasoning was this: if opium by its 
action on the nervous system quiets brain cells and lessens 
the functional activity of the nervous fibrils which connect 
them ■R'ith one another, if it lessens pain and removes the 
effect of peripheral stimuli, if it contracts cerebi;3l arteri- 
oles and through the cardiac ganglia renders the heart's 
action slower and vascular pressure less pronounced, then 
its effect upon a brain that is traumatically damaged and 
that demands quiet for its repair can only be beneficent. 
He had found that if after severe brain injury the patient 
was kept under the influence of morphine convalescence 
was more rapid and steady, grave cerebral symptoms had 
been wanting, and the continuous rise of temperature had 
been notably absent. A short record of cases was given 
to strengthen his contention. 

British Medical Journal, June 25, 1904. 

Hypodermic Injection of Quinine Sulphate. — G. F. 

Darker finds that ordinary quinine sulphate mi.\ed with 
about one and one-half times its own weight of vaselin 
makes a .suitable mixture to inject under the skin of the 
natives in \\est Africa to lessen the malarial index. A 
mass containing 15 to 20 gr. of quinine after injection 
takes about three and one-half months to absorb. During 
that time the writer has failed to find malarial parasites 
in the children on whom he has tried this mixture. An 
ordinary metal hypodermic syringe will suffice. The 
whole proceeding must be done under asejitic precautions. 
It is well to give at the same time a dose of quinine by 
mouth or an intramuscular injection of the same drug. 
The left side of the abdomen near the fiank is the most 
suitable site for injection. 

Acute Dermatitis Produced by Satin-wood Irritation. — 
H. E. Jones gives an account of two distinct outbreaks of 
acute dermatitis occurring among a number of joiners and 
cabinet-makers. The exposed parts are those affected. 
The first thing noticed is an irritation on the skin; later 
on the parts become hot and red, and subsequently be- 
come swollen and uncomfortable, and although not painful, 
the patient cannot sleep well. Still later the parts be- 
come moist and complete desquamation takes place. The 
first attack is rather slow in its onset, but relapses come 
on with great rapidity. After desquamation, the new 
skin would be more easily irritated than the old. The 
cause of this dermatitis seems to be irritation caused by 
East Indian satin-wood dust. .>\s to treatment, it ha!s 
been suggested that the men should remain off duty till 
the epidermis is fairly strong, and that then vaselin or 
some oily substance be smeared over the exposed parts 
while the men are at work. 

Intrauterine Infection of the Foetus in Smallpox. — 

James M. Cowie and Duncan Forbes speak of three cases 
they have seen of infants attacked with smallpox so soon 
after birth as to warrant the conclusion that they recei\-ed 
the Infection while still in utero. Considering the interval 
between infection and the appearance of the rash as the 



July 9, 1904] 



MEDICAL RECORD. 



69 



usual one of fotirteen days, the first child must have been 
infected on or about the date of onset of the mother's 
illness and three or four days before birth; in the second 
case the time must have been six days before the onset in 
the mother and seven days before birth, and in the third 
case five days before the mother sickened and seven days 
before birth. These children were all born about full 
time. Two other cases are mentioned by the writers: 
One was tliat of a woman in the seventh month of preg- 
nancy who developed a discrete attack of smallpox. She 
was discharged from the hospital about a month after 
admission. The child was bom about a month after 
discharge and showed no signs of having had smallpox. 
It was successfully vaccinated. Thus, no immunity was 
conferred on the child by the mother's attack. The other, 
a five-months fixtus bom in the fourth week of the mother's 
illness, showed no signs of smallpox. The liability of the 
fietus to smallpo.x appears to increase directly with its 
age. 

Deutsche mcdizinischc Wochenschrifl, June 16, 1904. 

Therapy and Prophylaxis of Chronic Malaria. — Bassenge 
reports two cases contracted in the tropics, in which the 
continued administration of quinine was without effect 
in inhibiting the attacks or in preventing their recurrence. 
One patient had taken a half gram every fourth day for 
almost a year as a prophylactic measure, and yet became 
infected with malaria, the parasite of which could be 
demonstrated in the blood with certainty after the reac- 
tion following the injection of tuberculin. In the other 
patient the prophylaxis was also inefficient and the quinine 
given subsequently had no effect. A blood examination 
had never been made and the type of fever was unknown . 
After this had been determined by careful examination 
to be of the quartan type and the quinine administered 
at the proper moment, the disease was cured. This 
shows the necessity of knowing exactly when to give the 
quinine, as in this case the drug had no effect, and brought 
on, moreover, an obscure series of nervous symptoms. 
Unless the microscopical examination is made, therefore, 
the ordinary clinical diagnosis of malaria is of little value 

Late Recurrences of Carcinoma. — ^Jordan believes that 
the question of complete recovery from carcinoma can 
only be determined after the lapse of another twenty or 
thirty years, when a series of observations are available 
which have extended over several decades. The reports 
of isolated cases which have remained free from recur- 
rences for prolonged periods are not always conclusive, 
for, as the author's observations show, late recurrences 
even after fifteen years, are not imcommon. He claims 
that one of the main factors in determining recurrences 
is in the individual character of the growth, and this 
varies within wide limits. The first case which he reports 
is a carcinoma of the tongue, where a recurrence took 
place after nineteen years after complete operative 
extirpation. The lymphatics were not involved at 
either time, which may be taken as an indication of the 
more or less benign character of the growth. The other 
case was a mammary carcinoma which ran a chronic course 
and showed recurrences every few years for fifteen years. 
It seems that this also was a mild form of the tumor, 
with diminished proliferative energy, so that minute par- 
ticles remaining occupied several years before attaining 
the size of a palpable nodule. The author thinks that 
the statistics thus far presented be subjected to a revision 
with this point in view, i.e. the late recurrences, it will 
be found that so-called cases of complete cure are merely 
cases with prolonged freedom rather than total freedom 
from recurrences. It is also necessary to distinguish 
between the tumors which recur rapidly and those which 
recur after the lapse of a longer period. 

A Substitute for Both Ureters. — James Israel calls at- 
tention to a class of cases in which a congenital obstruction 
to the urinary flow may be followed by a hydronephrosis 
which may gradually attain a considerable size withotit 
the production of any symptoms, and then suddenly 
manifest its presence by the development of a severe acvite 
illness. This may take the form of cohc, due to the in- 
creasing tension in the sac, or of septic fever and renal 
pain, due to an acute infection of its contents. Both of 
these conditions were well marked in the author's case, 
in which, in a thirteen-year-old boy, there was a large hy- 
dronephrosis in each kidney due to congenital disturbances, 
which was not detected xmtil colic on the right side, and 
an acute infection of the sac on the left side, led to the 
discover}' of the true state of affairs. Operation was first 
done for the condition on the left side, and hei^e the 
hydronephrosis was foimd to have been caused by a con- 
genital displacement of the kidney, and it w-as determined 
to secure better urinary drainage by shifting the origin of 
the ureter to the lowest point of the renal pelvis. This 
was accomplished by shortening the blind pouch by 



making a longitudinal incision and then suturing it in 
a horizontal direction. The procedure failed, however, 
in producing any more perfect drainage, and a few days 
later renal puncture was resorted to in order to relieve 
the symptoms. Soon after infection of the left kidney 
took place, which was then communicated to the right. 
Every known method was tried in attempting to relieve 
the patient and restore the normal passage between 
kidney and bladder, but -without success. It was then 
decided to secure this end without the medium of the 
ureter, and a fistulotis communication was devised 
between the bladder and the pelvis of the kidneys with 
the aid of a system of tvibes, similar to what had Ijeen 
done in another patient with a solitary renal fistula 
(described in Deutsche medizinische Wochenschrijt, 1903, 
No. i). The appliance had been in good working order 
for over a year and the boy is in good general health. 
Twice a week the tubes are changed and the bladder and 
pelvis irrigated with boric acid solution. Notwithstand- 
ing the success of this procedure, the author still hopes 
to arrive at the same result bj* doing a resection of the 
ureter and implanting the same in the most dependent 
portion of the renal pelvis, which after the obstructions 
have been removed can be made smaller and will remain 
thus . 

Berliner klinische Wochenschrijt, June 13, 1904. 
Gonorrhoea! Stomatitis in Adults. — Jurgens believes 
that this process not only has a distinctive etiology, but 
also presents a distinct clinical picture. The patient, 
in the case which is reported, shortly after the appearance 
of a gonorrhrcal urethritis, developed a diffuse inflamma- 
tion of the mucous membranes of the gums and the cheeks. 
These were covered with a dirty gray membrane, which 
could be readily wiped away, but there was ulceration. 
In smear preparations the gonococcus was identified with 
difficulty, but better success was had with cultural tests. 

M iinchencr inedizinische Wochenschrijt. June 14, 1904. 

Operations Conducted Alternately by Daylight and the 
X-rays. — Grasey has devised an apparatus by which 
it is possible to operate with both of these sources of light 
as when looking for a foreign body imbedded in the 
tissues, such as a needle. The apparatus is so con- 
structed that one eye of the operator may be employed 
in looking at the .r-ray picture, while the other is engaged 
in following the steps in the operation on the part under 
treatment. The principle involved is like that in a camera 
lucida such as may be attached to a microscope for draw- 
ing purposes. 

A Case of Trypanosome Disease in Man. — Gunther and 
Weber report a case of this tropical disease, which is ap- 
parently the first observed on the continent of Europe. 
The patient had been in South Africa and returned to 
Europe, where he became afl3icted with what at first 
thought to be malaria. The main points in the history, 
which is reported in great detail, are as follows: the 
chronic course of the complaint extending over two j^ears, 
recurrent irregular attacks of fever, loss of strength and 
decrease in the haemoglobin, locaUzed transitory a-demas, 
pecuHar erythematous eruptions, enlargement of spleen 
and liver, which was more marked during the acute ex- 
acerbations, slow pulse and occasional dyspnoea, com- 
bined with abnormal irritability of the circulatory system. 
In addition there appeared an inflammatory process on 
the leg resembling the early stages of a phlegmon. As in 
the other cases reported, it was possible to demonstrate 
the presence of the trvpanosomes in the blood during the 
attacks of fever. A "further communication is promised 
on the results of treatment given. 

Diagnosis of Typhoid Fever. — Roily reports on the re- 
sults of his observations with Schottmuller's method, by 
which the typhoid bacilli can be demonstrated in the 
patient's blood. By the aid of a syringe, 20 c.c. of blood 
are abstracted from" one of the arm veins and rnixed with 
glvcerin agar at a temperature of 42° to 45' C. This is 
po'ured out in Petri dishes placed in an incubator for 
one or two days, and then examined. In fifty cases of 
typhoid subjected to this test cultures of the specific 
bacillus were obtained in 44; i.e. in 88 per cent. The 
number of colonies varies within w-ide limits, but it 
seemed that the larger numbers were associated with the 
early stages and the height of the disease. In sixteen 
cases it was found that during the earlv days of the 
disease the agglutination tests were negative, while the 
bacilli could be demonstrated in the blood, and as doubts 
of the true conditions usually exist during the first day 
such a method of diagnosis ought to prove of exceptional 
value. In general practice it is somewhat difficult to 
carrv out this procedure and the writer proposes certain 
modifications. As it is necessary to keep the blood 
fluid, he advises mixing the blood as soon as it is ab- 



7° 



MEDICAL RECORD. 



[July 9, 1904 



stracted with 20 c.c. of a solution made up of peptone 
5 gm.; grape sugar, 50 gm.. in 100 c.c. of water. This 
IS boiled from five to ten minutes. Blood to which this 
solution has been added remains fluid for a day, and can, 
therefore, be transported to a place where the proper 
laboratory facilities are obtainable. It was also sought 
to improve on the agglutination tests by substituting 
for the cultures of living bacilli a fluid in which the dead 
bacilli could be held in suspension. This was accom- 
plished by killing the typhoid bacilli in a bouillon cul- 
ture with formol. Experiment showed that agglutination 
takes place in the same dilutions, with the bouillon con- 
taining the dead, a.s that containing the living bacilli. 
Blood serum which failed to agglutinate the one also failed 
in the case of the other. In the case of the dead culture, 
agglutination takes place about fifteen to thirty minutes 
later, but is evident on either micro- or macroscopical 
examination. The bouillon containing the dead bacilli 
may be kept for considerable periods and still retain its 
efficienc}-. 

French and Italian Journals. 

Influence of the Soil on the Virulence of the Vibrio of 
Cholera. — A. Paladino-Blandini made cultures of the 
vibrio of cholera in dry earth, in moist earth free from 
organic matter, and in earth that was impregnated with 
fecal matter. In dry earth the virulence was decreased; 
in moist earth it was less rapidly diminished; in earth 
impregnated with a considerable amount of organic matter 
its virulence was increased. But if between two periods 
of remaining in the earth it passed through the body of 
an animal, its virulence was very markedly increased. 
Both its presence in the earth and in the animal were 
important factors in the increase of virulence. There 
seems to be a coincidence between the presence of the 
vibrio in the deepest levels of the subterreanean water, 
where the sun does not reach, and the coming of a severe 
epidemic of cholera. — Giornale Internationale delle Scicnze 
Mediche, May 15. 1904. 

Chorea in Pregnancy. — Vallois reports the case of a 
woman of twenty-si.x years, a primipara, who toward the 
end of the eighth month began to exhibitjslight arrhythmi- 
cal movements in the arms, and certain psychic disturb- 
ances. These movements increased till the whole body 
was involved. The child was bom, but the cerebral 
troubles persisted. The patient had auditory hallucina- 
tions, and thought she heard voices calling her name. 
There was anaesthesia of the conjunctiva and of the 
pharynx, but no cutaneous an.-esthesia. Then the choreic 
movements began to disappear, and instead of the 
phenomena of excitement, those of depression succeeded. 
The patient was badly nourished and became emaciated. 
Since labor there had been no rise of temperature. The 
pulse, which remained for a long time 104 to 112, rose 
finally to 132. The mental troubles grew wor.se. and the 
patient was sent to an asylum. This case is like most 
of its kind. The chorea is of an hysterical nature and not 
rheumatic. — LaMedecine Moderne, June 8, 1904. 

Laryngeal Syphilis. — A. Ohauffard and Paul VioIIet 
discuss this subject and present the history of several 
patients. They call attention to the predominance of 
nocturnal symptoms. A chill often ushers in the acute 
phenomena of syphilis. It is sometimes very difficult to 
differentiate syphilitic laryngitis from cancer, sarcoma, 
lupus of the larynx, and laryngeal tuberculosis. Ordi- 
narily syphilitic infiltrations are indolent .while the ulcera- 
tions have a relatively rapid evolution. Cancer has a 
tendency to vegetate first, it is complicated v.-ith adenitis 
and its evolution is in general far more slow. In lupus 
there is generally noted the process of spontaneous 
cicatrization side by side with active lesions. The evolu- 
tion of these lesions is still slower than in the case of 
laryngeal tuberculosis. The latter often presents the 
manipulations of acute or chronic cedema which are seldom 
seen m syphilis. The epiglottis is often attacked by the 
latter, while the arytenoids, especially, are attacked in 
tuberculosis. Finally, syphilis is not accompanied by 
concomitant pulmonary symptoms. The possible com- 
bination of syphilis with cancer or tuberculosis must be 
remembered. Syphilitic lesions capable of affecting the 
larj-nx and of givmg the laryngoscopical image of paraly- 
sis are very varied. In order to establish a'diagnosis of 
syphilitic laryngeal affections, a general examiriation of 
the patient must be made including an exploration of the 
ganglia of the neck, the lungs, the aorta, the thorax and 
Its contents, the reflexes and the entire nervous system. 
Lumbar puncture is sometimes helpful in cases of sus- 
pected tabes. Laryngoscopical examination is most im- 
portant. — Gazette des Hdpitaux Civils et Militaires, Time 
0, 1904. 

Annals of Surgery, June, 1904. 

Sarcoma of the Tongue.— C. B. Keenan finds only 
about three dozen cases of this nature on record. He 



adds one personal case The patient was unwilling to 
undergo a radical operation though various portions 
of the tumor, in fact, almost all of it, was removed. He 
died some months later from recurrence in the abdomen, 
but examination at this time showed no signs of re- 
currence in the tongue. The author then gi\-es a synop- 
sis of the recorded cases. Analysis shows that they 
were all of the round-celled variety. The majority of 
them occurred between the fortieth and fiftieth year. 
Extensive metastases were the rule. Generally the 
growth was slow. They are distinguished from can- 
cerous growths by the fact that the epithelium usually 
remains intact or ulcerates only after a long period. 
From gummata they are distinguished by the thera- 
peutic test. Under the microscope, however, it is not al- 
ways easy to distinguish a gumma from small-celled 
sarcoma. Wide excision is the only rational therapy. 

Revival of Suprapubic Prostatectomy. — The object 
of the article of F. D. Gray is to call attention to the 
views of Freyer, whose work the author has been able 
to follow by personal observation. Freyer contends 
that a certain class of enlarged prostates, notably the 
large cedematous type, which he considers more com- 
mon than do other authorities, can most safely and 
easily be reached by the suprapubic route with perfect 
restoration of bladder ftmction and with a very small 
mortality. His method is one of enucleation through 
the upper route. His procedure is based on the work 
of Sir Henry Thompson, who taught that the prostate 
has a thin, closely adherent, fibrous covering, dipping 
between the lobes of the gland, and from which it cannot 
be enucleated; also that outside this capsule is another 
covering (which Freyer terms the sheath), in reality the 
layers of the rectovesical fascia, between which and the 
capsule is a natural "line of cleavage." Freyer's com- 
parison of the prostate capsule, and sheath to an orange, 
with its closely adherent inner skin which dips between 
the various sections and is surrounded by the rind, from 
which it is readily enucleated, most perfectly conveys 
the anatomical idea on which his suprapubic enucle- 
ation is based. He calls attention to the fact that 
in fetal life the prostate is double — two lateral halves — 
and that later they are only united by the upper and 
lower borders, thus enclosing the urethra, while in the 
advanced adenomatous enlargement these connections, 
especially the upper, easily give way, facilitating their 
separation from the urethra. 

Extensive Subcutaneous Laceration of the Abdominal Mus- 
cles. — -D. N. Eisendrath reports the case of a man of fifty 
years who, while intoxicated, was caught between two 
street cars pa.ssing in opposite directions. He was 
admitted to hospital and presented a swelling about 
the size of an orange at the middle of the right iliac crest 
and extending somewhat below it. From the fact that 
this tumor was distincth' tympanitic on percussion 
and could be made to disappear into the abdominal 
cavity with a gurgle, he made the diagnosis of a trau- 
matic hernia throtigh the triangle of Petit. There 
were several other minor injuries. Operation was done six- 
teen hours after admission to hospital. Incision over 
the site of the iliac swelling showed that only the skin 
separated the peritoneal cavity from the external world. 
All of the muscles attached to the crest of the ilium 
(external and internal oblique, and transversalis muscles), 
as well as the transversalis fascia and peritoneum, were 
torn loose from their attachments. The skin incision 
was enlarged in both anterior and posterior directions, 
and the flaps retracted. It was then found that the 
injury was far more extensive than at first supposed. 
From the quadratus lumborum posteriorly to the middle 
of Poupart's ligament in front every structure which 
is normally attached to the crest of the ilium and outer 
half of Poupart's had been torn from its attachments. 
The lower edges of the muscles were irregularly torn and 
contused. The general peritoneal cavity had already 
been partly walled off by adhesions between the as- 
cending colon (which had been displaced inward) and 
the anterior abdominal wall. In the iliac fossa were 
many loose pieces of omentum. The ascending colon 
was contused and dilated. By means of fourteen kan- 
garoo tendon sutures the muscles were drawn down 
to the gluteal fascia and the defect closed. From the 
anterior superior spine of the iliuin to the middle of 
Poupart's ligament, mattress sutures of kangaroo ten- 
don were passed in a similar manner through the muscles 
en masse, and these then anchored by passing the two 
ends of the suture through Poupart's ligament itself, 
similar to the formation of the posterior wall of the 
inguinal canal in the Bassini operation. Small gauze 
drains were inserted at each end of the long skin incision. 
These were remo\-ed after forty-eight hours. Primary 
union occurred and the patient made a slow, though 
complete recovery. 



July 9, 1904] 



MEDICAL RECORD. 



71 



La'^ Separation de l'Urine des Deux Reins. Par 

Georges Luvs. Assistant du Service des Voies Uri- 

naires a I'Hopital Lariboisiere. Preface par Henri 

Hartmann, Professor Agrege a la Faculte, Chirurgien 

de I'Hopital Lariboisiere, Paris: Masson et Cie., 1904. 

Renal surgery is a subject to which a vast amount of study 

is being devoted at the present day and, apart from the 

surgical treatment of Bright 's disease, no branch of this 

department is of greater interest than that of diagnosis 

by examination of the urine obtained from each kidney 

separately. Among the methods of obtaining the urine 

of one kidney immi.xed with that secreted by the other, 

that of Luys stands out most prominently. 

In the present work the author, after showing the ne- 
cessity of this means of diagnosis, reviews and explains 
the different methods (ureteral catheterism, compression 
of the ureter, and intravesical separation) .jand then treats 
of his own device, dwelling on the history of its invention, 
its construction, method of employment, action, and 
indications. Excellent results are shown in the re- 
ports of personal cases, 210 in number, in which the 
separator has been used on patients of both sexes and 
all ages, and with every imaginable disease of the kid- 
neys. Many of these reports are illustrated with well- 
executed pictures of the kidneys removed after diagnosis 
by Luys' method. The author has not been precipitate 
in the recording of his cases, but has waited three years 
and has demonstrated the value of his invention over 
two hundred times — an experience which gives him the 
right to speak with authority. 

The book is a timely one, and will be consulted with 
profit by all who are interested in renal pathology. 
Theorie vnd Praxis der Augenglaser. Von Dr. E H. 
Oppenheimer, Augenarzt in Berlin. Mit 181 Textab- 
bildungen. Berlin: August Hirschwald, 1904. 
The volume is one of 200 pages, and isprincipallj- devoted 
to the description of the various kinds of eye-glasses and 
spectacles and the theory and art of their construction. 
In the first chapter a short history of eye-glasses dating 
back to iSoo B. C. is found. The volume of production of 
spectacle lenses at the present time is mentioned. The 
second chapter describes the manufacture of the ordinary 
forms of eye-glasses ; the third, spectacles. Chapter X is 
devoted to a description of the proper way of adjusting 
glasses to the face. Chapter XI describes in detail the 
various kinds of glass employed in the manufacture of eye- 
glasses. Chapter XIII treats of the various ways of 
numbering glasses. 

The book is well illustrated. It is calctilated to acquaint 
ophthalmologists with what is being done in the art of 
making eye-glasses, and this purpose it accomplishes in a 
very excellent manner. 

A System of Practical Surgery. By Drs. v. Berg- 
MANN, Berlin, v. Bruns, Tubingen, and v. Mikulicz, 
Breslau. Edited by Wm. T. Bull, M.D. Vol. II, 
Surgery of the^Neck, Thorax, and Spinal Column. New 
York and Philadelphia: Lea Brothers & Co, 1904. 
The second volume of this work closely follows the ap- 
pearance of the first, and the remaining three volumes of 
the series are scheduled to come out in rapid succession. 
It includes the surgery of the neck, thorax, and spinal 
cord, and in the list of contributors are the names of v. 
Angerer, v. Bruns, Erhard, v. Eiselberg, Henle, Hof- 
meister, Jordan, Kummell, and Riedinger. Their names 
are not in all cases, however, appended to the chapters 
in the book for which they are responsible, in some 
respects an unfortunate omission. The following topics 
are considered: Malformations, injuries, and diseases of 
the neck, the larynx and trachea, thyroid gland, thorax 
and its contents, the mammary gland, the spinal cord, 
and the vertebral column. In the latter chapter the sub- 
ject of tuberculous spinal ostitis is considered, as regards 
diagnosis and treatment, quite as fully as in some special 
textbooks on the subject. In this, as well as in other 
parts, one is impressed by the evident desire to make the 
work practical; more space being given to diagnosis and 
treatment than to etiology or pathology, except w-hen 
one has a bearing, on the other. The typographical work 
is up to the high standard to be found in most American 
medical books, and the illustrations are ntimerous. 
An Introduction" to Vertebrate Embryology, based 
on the study of the frog and the chick. By Albert 
MooRE Reese, Ph.D. (Johns Hopkins), Associate 
Professor of Histology in Syracuse University and 
Lecturer on Histology and Embrj'ology in the College 
of Medicine. New York: G. P. Putnam's Sons, 1904. 
This volume contains 291 pages and 84 illustrations. 
It is, the author tells us, the result of a need for a text- 
book on the embrj'ology of the chick and frog, at once 
concise and convenient. The volume is intended as an 



outline from which the instructor can expand as he see* 
fit. The needs of the medical student have been largely 
considered, and very little space has been devoted to 
theoretical discussions. The treatment of the subject is 
convenient for the student, the development being de- 
scribed day by day (for the chick, for example, daily up to 
the sixth day), instead of organ by organ. The text is 
clear and easily followed, and devoid of unnecessary 
technicality ; and the illustrations are well selected. 
All in all, this little volume forms a convenient manual 
for the student. 

The Therapeutics of Mineral Springs and Climates. 
By I. Burney Yeo, M.D., F.R.C.P., Emeritus Pro- 
fessor of Medicine in King's College, London, etc. 
Chicago; W. T. Keener & Co., 1904. 
Dr. Yeo has become well-known to the profession on 
this side of the Atlantic through his excellent "Manual of 
Medical Treatment," and his attractive monograph on 
"Food in Health and Disease." The present volume 
may also be classed as a useful work of reference. Part 

I (456 pages), comprising about two-thirds of the book, 
treats of mineral springs and contains chapters on the 
nature and composition of mineral waters, their action 
and modes of application, with the various accessory 
methods employed in the internal and external use of 
waters, together with a description of the principal Euro- 
pean springs, arranged in alphabetical order. As no 
geographical limitation is expressed in the title, it would 
not have been out of order, nor would it have been prej- 
udicial to the practical value of the work, to have in- 
cluded some of the American springs, many of which will 
take rank with the best of those found in Europe. Part 

II relates to the subject of climate, and contains an ac- 
count of the several varieties of chmates with a brief de- 
scription of the various British and Continental winter and 
summer resorts, the therapeutics of sea voyages, the 
uses of sanatoria, etc. In this part of the book the atithor 
far transcends the geographical limits allotted to mineral 
springs and takes his readers as far afield as South Africa 
and the Pacific Coast of the United States. It is grati- 
fying to obser\-e that while Dr. Yeo is an ardent 
advocate of the modem sanatorium treatment of tuber- 
culosis, he is by no means to be classed with the latter-day 
group of extremists who taboo the subject of climate as 
being quite negUgible in the management of this disease. 
We think no one can read the excellent chapter on climatic 
therapeutics without being impressed by the forceful logic 
of the author's views. 

The Complete Medic.\l Pocket-Formulary and Physi- 
cian's Vade-Mecum. Containing upward of 2,500 
prescriptions, collected from the practice of physicians 
and surgeons of experience, American and foreign, 
arranged for ready reference under an alphabetical list 
of diseases. Also a special list of new Drugs, with their 
Dosage, Solubilities, and Therapeutical AppUcations, 
together with a table of Formula; for Suppositories ; a 
table of Formula? for Hypodermic Medication; a list of 
drugs for Inhalation; a table of Poisons, with their 
Antidotes; a Posological table, a Hst of Incompatibles ; 
a table of Metric Equivalents; a brief account of Ex- 
ternal Antipyretics, Disinfectants, Medical Thermome- 
try, the Urinary Tests ; and much other useful informa- 
tion. Collated for the use of Practitioners by J. C. 
Wilson, M.D., Physician to the German Hospital, 
Philadelphia, etc. Third Revised Edition, Philadelphia: 
J. B. Lippincott Co., 1904. 
Being alphabetically arranged, this presents a handy 
reference book. There are nearh' 2,600 formute. Why 
they should be numbered does not appear. The "list of 
authorities " seems superfluous. — The lists of new remedies, 
poisons, measures, etc., are good. 

Immune Sera: H.-emolysins, Cytotoxins, and Precipi- 
tins. By Prof. A. Wassermann, M.D., University of 
Berlin. Authorized Translation by Charles Bolduan, 
M.D. New York: John Wiley & Sons; London: Chap- 
man & Hall, Limited, 1904. 
The subject of serum diagnosis and therapy, already 
grown to considerable proportions, is constantly increasing 
in importance. The lack in our language of any simple 
and concise exposition of the subject has led Dr. Bolduan, 
as he tells us in his preface, to make this excellent treatise 
of Prof. A. Wassermann more readily accessible to the 
English-reading medical public. For this the thanks of 
many are due him, for the subject is presented by the 
author in a way which leaves little to be desired by the 
seeker after information who has not the time or the oppor- 
tunity to study at first hand and in large treatises the 
details of this difficult science. Any one, by one or two 
careful readings of this little book of 76 pages, can famil- 
iarize himself with the whole theory of immunity, as it is 
at present held, and so be in a position to understand 
much in modern medical literature that else must be to 
him a sealed book. 



72 



MEDICAL RECORD. 



[July 9. 1904 



AMERICAN SURGICAL ASSOCIATIOX. 
Twenty-Fifth Annual Meeting, Held in St. Louis, June 

14, 15, 16, and 17, 1904. 
The association met in the Assembly Hall of the Board 
of Education, under the Presidency of Dr. N. P. Dand- 
ridge of Cincinnati, Ohio. 

President's Address. — Dr. X. P. Daxdridge depiarted 
somewhat from the practice of his predecessors, and 
instead of bringing before the association some medical 
topic based on his own work, or attempting a discussion 
of some subject of active interest, he took the members 
to the back woods, and interested them in the life and 
exploits of a pioneer doctor. He depicted a man of 
high scientific attainments and true culture, with all the 
elements of character which become the doctor and the 
man. He gave an exhaustive sketch of Antoine Francois 
Saugrain de Vigni, who was bom in Paris, February 17, 
1763. He came from a long line of librarians, booksellers, 
and printers, who, as far back as Charles IX in Lyons, 
and Henry of Xavarre, had served the Royal family in 
France. His knowledge of mineralogy made his advice 
often called for in the development of the mines in the 
Ohio Valley. In the wilderness he supplied himself 
with ink from a natural Chalybeate water and an infusion 
of white oak bark, and when in need of a fire, lighted 
it from a lens made by two water crystals with clear 
water between. Dr. Saugrain gave notice of the first 
vaccine matter brought to St. Louis, and indigent persons 
were vaccinated gratuitously. He practised in St. Louis 
till his death, in 1820. He must have been eminently 
successful, for he left a large landed estate for the support 
of his wife and six children. His scientific work lives 
in tradition, and has gained for him the title of the 
"First Scientist of the Mississippi Valley." 

What Are the Minimum Requirements for Aseptic Sur- 
gical Operations in Hospitals Where the Surgeon Is Assisted 
by a Large Staff of Internes and by Nurses from a Training 
School? — This subject was discussed with great detail by 
Dr Geo. H. Mo.vks of Boston, Mass. 

Minimum Requirements for Aseptic Operations in a 
Hospital in Which the Personnel of the Operating-room 
Is Permanent. — Dr A J. Ochsner of Chicago, in a paper 
on this subject, pointed out the fact that with a per- 
manent personnel a definite system could be developed, 
which was most satisfactory, because the observations 
which suggested changes as well as those which con- 
firmed satisfactorj' methods could be carried through 
a large continuous series of cases under unchanged ex- 
ternal conditions. Stress was laid upon the importance 
of simplicit5' in the methods chosen The less that was 
done in any given case, the slighter was the likelihood 
of doing harmful things. There should be uniformity 
in carrying out a plan of work in order that everyone 
connected with the system might know what had been 
done and what was to be done by the other members 
of the personnel in any given case. Above all things, 
the methods should be reasonable in their details. This 
would make the work more attractive, and consequently 
more satisfactory to those engaged in its prosecution. 
The author then gave a detailed account of the system 
followed by him and his assistants at the Augustana 
Hospital, where he had had an opportunity to develop 
uniform methods with permanent conditions during a 
period of fifteen years. The sj'stem comprised disinfec- 
tion of patient, operator, assistants' and nurses' hands, 
instruments, silk, silkworm gut, horsehair, drainage 
tubes, hand brushes, dressings, implements, towels, 
sheets, etc. Stress was laid particularly upon the danger 
arising from tying sutures too tightly, thus causing press- 
ure necrosis, which favored the development of micro- 
organisms accidentally introduced. The method of 
selecting assistants and nurses was described, and a table 
llustrating the manner in which each assistant recorded 



the progress of the wounds under his care was appended. 
Dr. Ch.^rles H.\rrington of Boston, Mass., read a 
paper, by invitation, in which he detailed his studies in 
asepsis. 

Dr. De Forest Will.\rd of Philadelphia said that 
surgeons who had to deal with the practical side of asepsis 
in surgical operations knew that their results satisfied 
them to a certain degree, but it must be confessed that 
they had failures, and it was very essential to know 
whether the failures were due to the method or methods 
employed, or whether there were difficulties which could 
not be overcome. Difficulties would beset surgeons, but 
the question resolved itself largeh' into one of extreme 
care on the part of everyone, from the surgeon down to 
the lowest assistant, who had the materials in charge or 
in preparation. There could be no doubt that a hospital 
which had permanent assistants, permanent nurses, was 
the one that was likely to secure the best results from 
operative procedures on the patients under its care. 

Dr. Chari,es B. Xaxcrede of Ann Arbor, Mich., 
emphasized the two important points, one of which was 
inhibition, and the other, tissue resistance. A germ 
might be inhibited to the point that would render it safe 
in a given wound. 

Dr. John E. Owe.vs of Chicago stated that different 
results were reported by different surgeons after using 
the same methods, and he had often wondered whether 
some of them might not have been due largely to the habits 
of surgeons. So far as the disinfection of hands was 
concerned, a few years ago he was compelled to stop the 
use of corrosive sublimate on account of the condition 
of his hands, and since then he had been scrubbing them 
thoroughly with soap and water, keeping the nails of the 
fingers pared down, and afterward washing the hands 
with salt solution and alcohol, and he thought his results 
were as good in hospital work as where other chemicals 
for sterilization were used. 

Dr. W. W. Keen of Philadelphia spoke of his own 
method and the results which he had obtained by some 
experiments. He had adopted for several years past 
for the cleansing of his hands, a method which was first 
directed to the attention of the profession by Weir, namely, 
the use of chloride of lime and carbonate of soda. The 
hands were washed thoroughly with soap and water, and 
in order to do this he had in his own private hospital and 
at the clinic at Jefferson, little egg boilers, which were 
practically hour-glasses or sand-glasses that were re- 
versible. These were marked "soft-boiled, well done, 
and hard Ixiiled. " Soft boiled corresponded to about 
three minutes; well done, five minutes, and hard boiled, 
seven minutes. He told his assistants that when they 
had scrubbed their hands until the sand had reached 
"well done, " good and faithful servant, they should stop. 
Every person, who took an active part in his clinic, had 
a culture taken from under the thumb, or one or two 
finger nails, particularly at the root of the nail, and from 
the free surface of the skin. During the last winter there 
were 213 cultures made, from the hands of himself and 
his assistants in the clinic at Jefferson. Of this number 
there were only three cases in which any culture was 
obtained. This made practically a sterility of 9 per 
cent., and an infection of about 3 per cent. There was 
but one person who was free at every clinic, and that 
was the head nurse, who was a permanent official in the 
operating room. All the other nurses, and' all the assistants, 
except this principal assistant, changed even,- three 
months. He thought the method of keeping such a 
record of every person's hands ser\-ed an admirable 
purpose by creating a sort of ri\aln.- among those who 
were endeavoring to have clean hands before operation, 
and it was more to prophylaxis in preventing infection 
than in the results obtained, he attributed the value of 
the method. 

Dr. W. B. CoLEY of Xew York did not believe suf- 
ficient stress had been laid upon sterilization of the skin. 



July 9, 1904] 



MEDICAL RECORD. 



and although some authorities maintained it could be 
done properly in a few moments before operation, his 
experiments showed that with careful preparation the 
day before operation, in addition to what was done on the 
day of operation, sterilization of the skin even then could 
not be said to be perfect. In 250 cases in which he had 
examined portions of the skin or Reverdin grafts, taken 
from the field of operation immediately before, 25, or 
9 per cent. of the cases, showed all kinds of cultures, some 
of them being staphylococcus and streptococcus. The 
only case of suppuration in two hundred cases showed 
a pure culture of the streptococcus. Carefully sterilizing 
the hands, using tincture of green soap, applied carefully, 
brushing and hot water, then washing thoroughly with 
95 per cent alcohol, with the use of rubber gloves, would 
give as good results as any of the measures which render 
the hands \ery hard. With reference to primarj' union, 
an important element in aseptic surgery was to guard 
against the bruising of tissues. 

A Clinical Review of Forty-Bix Operative Cases of 
Duodenal Ulcer. — This was the title of a joint paper by 
Dr. Christopher Graham and Dr. Wm. J. Mayo of 
Rochester, Minn. The authors stated that a careful 
history was of prime importance. The leading symp- 
toms in the forty-six cases reported were, first, pain, 
which might be due to peritonitis, distention from gas 
formation, pyloric spasm, and the irritation of acid gastric 
contents on open ulcer. The pain might come on in 
colics or last for some hours. Second, vomiting, prin- 
cipally of sour, bitter liquids, or if obstruction supervened 
of food after varying intervals. Third, gastric insuf- 
ficiency from interference with drainage. There was 
usually hyperacidity of gastric contents, constipation, 
and a great desire for food, although the patient reduced 
the diet, and ate often a small quantity, but might fail 
to get the relief sometimes obtained in gastric ulcer proper. 
In latent cases, evidences of blood in the fecal movements 
might be the only sign. Differential diagnosis from 
pyloric ulcer in some cases might be impossible. A con- 
siderable number of cases closely resembled gallstone 
disease, and differentiation often could not be made. 
Such an error in diagnosis did not militate against the 
clinician, as both conditions were purely surgical and 
the differentiation in many cases must be made on the 
operating table. During the past eighteen months, 
27 per cent, of their operative gastric and duodenal ulcers 
involved the duodenum in combination — 753.33 per cent. 
There were ^^ males, and 13 females; in 43 out of 46 
cases the ulcer was easily detected upon abdominal 
exploration as a thick, white, scar-like area. Liability 
of duodenal ulcer to perforate was greater than gastric, 
but more often safely protected by adhesions. Relatively, 
sterile contents was also favorable. In all cases the ulcer 
was situated in the first two and one-half inches below 
the pylorus, and entirely above the entrance of the com- 
mon duct of liver and pancreas, with its alkaline secre- 
tion, showing the effect of the gastric juices on the 
duodenal wall. In all doubtful cases of differentiation, 
between duodenal ulcer, pyloric ulcer, and gallstones, 
the authors recommended making an incision through 
the right rectus muscle, one inch to the right of the median 
line. Gastroenterostomy best met the indications, in 
that it diverted the gastric contents. In acute perfora- 
tion, suture was recommended, with suprapubic drainage, 
with after-treatment, and exaggerated Fowler's position, 
sitting posture. The 46 cases were divided into five 
groups: (i) Acute perforation of chronic ulcer, 4 cases, 
2 deaths. (2) Acute hemorrhage in chronic ulcer, i 
case, one death. (3) Duodenal ulcer with gastric com- 
plications, 25 cases, one death. (4) Duodenal ulcer, 
with gall-bladder and liver complications, usually due 
to adhesions from chronic peritonitis, 9 cases, one re- 
operation, no deaths. (5) Eight cases, chronic pain and 
distress with debility, no deaths. Total, 47 operations. 
46 cases. Five operations for acute conditions, with 



three deaths; 42 operations for chronic conditions, with 
one death. 

Dr. E. WvLLYs A.n-drews of Chicago had seen in the 
last year or two several cases in which a marked hyper- 
plasia, patches of exudate, with thickening of the wall of 
the duodenum, ulceration of the first inch and a half of 
the duodenum connected with a similar condition of the 
pylorus, had produced such a degree of massive thickening 
that clinically, at the time of operation, it was indis- 
tinguishable from carcinoma. In one such case the 
operation, which was a McGraw elastic ligature gastro- 
enterostomy, left him in a dissatisfied state of mind, as he 
feared he shotild have done a more radical extirpation, 
and yet, in this particular case, it was his fortune to do a 
second operation for obstruction a year after the first 
operation, and he found, very much to his surprise, abso- 
lute disappearance of the thickened massive wall, which 
had formed in the first place and simulated carcinoma. 
This was what Mayo himself called attention to, namely, 
when the obstruction was relieved, when the flow was 
permitted from some other point, the inflammation, or 
ulceration, at any rate, the hyperplasia disappeared at 
the point of irritation, and secondary to this again, when 
obstruction had been relieved by drainage below, the 
drainage below ceased to act, and again the opening be- 
came closed, so that the surgeon had to do sometimes a 
secondary gastroenterostomy. 

Dr. Joh.n- B. Murphy of Chicago said the practical les- 
son the paper taught was the frequency of occurrence of 
duodenal ulcer; that it was not recognized, and that it 
was not differentiated from gastric ulcer or gall-bladder 
disease, whether it was of infective or of stone origin. 

Dr. Alexander Hugh Ferguson of Chicago asked Dr. 
Mayo if he had outlined for himself the class of cases in 
which he would do a posterior gastroenterostomy: also 
the class of cases in which he would do gastrojejunostomy 
or Finney's operation. The speaker mentioned one case 
in which he did a pylorectomy, removing the end of the 
pylorus, and a portion of the duodenum, with an excellent 
result. 

Dr. Mayo, in closing the discussion, and m replying to 
the remarks of Dr. Ferguson, said he did not know that 
they had ever tried to excise any of these ulcers excepting 
in connection with Finney's operation. They were irreg- 
ular and thick; they led to large vessels, close to the 
common duct, and it was difficult to get a good stump. 
He thought the best thing to do was to make a gastro- 
enterostomy, which would afford, at least, temporary 
relief, but the gastroenterostomy opening was very likely 
to contract, so that food would after a time continue to 
pass down over the duodenal ulcerated surface, and some- 
times these patients would return for a second operation. 

Complete Removal of the Shaft of the Tibia, with 
Restoration of the Bone. — Dr. George Ben Johnson- of 
Richmond, Va., detailed seven cases of this operation. 

Dr. De Forest Willard said it was greatly to be 
regretted that not only the family physician, but many 
surgeons, treated such cases as Dr. Johnston had reported 
for rheumatism, when there was really no sign of that 
disease, and they were, from the beginning, cases of acute 
suppurative osteomyelitis. Then came the septic symp- 
toms. The physician treated them for typhoid fever and 
other conditions, until they drifted into the hands of sur- 
geons, with bones absolutely destroyed, the majority of 
them crippled for life, with deformity of the legs. These 
cases from their incipiency were virulent in type, and the 
only time for treatment was forty-eight hours after the 
onset, and the quicker the surgeon got inside the bone, 
the better. If cases of appendicitis demanded early op- 
eration, surely it was doubly important that cases of 
acute osteomyelitis should be diagnosed and operated 
early. 

Dr. A. J. Ochsn'Er stated that in a large porportion of 
cases in which the shaft of the bone was entirelv loose. 



74 



MEDICAL RECORD. 



[July 9. 1904 



when the periosteum was incised, if the bone was left in 
place, there would be a regenaration of a considerable 
portion of the apparently dead bone. If one took such 
cases as had been described, made an incision which 
extended from one end of the bone to the other, split the 
entire periosteum, made it necessar>' for the flow of lymph 
to be away from the tissues, left bone there as a bone 
graft, he had found in a considerable number of cases 
that there would be a regeneration of a large portion of 
this bone. 

Dr. John Collins Warren of Boston said the subject 
was one that should be thoroughly discussed, and a 
message given to the profession to realize the importance 
of this septic process, so that cases of acute osteomyelitis 
might be sent to surgeons early and treated properly. As 
to treatment, the great point was to prevent the spread of 
sepsis. This might be accomplished by trephining the 
bone, by proper disinfection, by a comparatively moderate 
operation, or, it might be necessary in certain cases to do 
quite a radical operation. 

Dr. P. S. Conner of Cincinnati, Ohio, said that in some 
of these cases the disease originated superficially. The 
cases were uniformly mistaken for erysipelas. The red- 
ness of the overlying skin was taken as an indication of 
the existence of the disease. Then, we had a condition 
simulating typhoid fever after the disease had existed for 
a considerable length of time, or rheumatism for a while, 
then typhoid fever, when the condition did not subside. 
Early boring of the lower end of the tibia would put a 
stop to the trouble. A moderate incision would not in- 
frequently end the trouble if boring did not. 

Dr. S. H. Weeks of Portland, Me., said that while many 
of these cases began as a periostitis, requiring a simple 
incision down upon the bone, there were many others 
which commenced as an acute osteomyelitis in the medul- 
lary canal, and he believed under such circumstances when 
an incision was made down to the bone, there should be 
an opening made into the medullary canal, and that canal 
drained. 

Unavoidable Post-operative Calamities in Abdominal 
Surgery. — Dr.'M.\URicE H. Rich.\ri)Sos' of Boston read a 
paper with this title, which was based upon his experience 
more especially in abdominal surgery, and related exclu- 
sively to fatal cases. Four classes of calamities were con- 
sidered: (i) Suppression of urine; (2) inexplicable deaths, 
with symptoms of local and general sepsis, but without 
any detectable bacterial source; (3) uncontrollable 
capillary hemorrhage; (4) p\dmonary embolism. Sup- 
pression of urine could be regarded as an unavoidable 
accident only when it took place after the urine had been 
shown to be normal by the most searching study. The 
influence of ether alone in causing suppression after 
operations was not regarded as sufficient and sole cause 
of this calamity. It was doubtless true that failure 
of the kidneys properly to perform their functions was due 
to some pathological change in the secreting substance, 
if not a pathological change, a tendency to glomerular 
irritation or real inflammation, but a change or tendency 
which could not be detected beforehand. Such suppres- 
sion of urine, however, might be prevented by the avoid- 
ance of all but imperative operations whenever there was 
the least evidence of renal disease, especially an insuf- 
ficiency in the elimination of urea. Renal suppression 
was not believed by the writer to be the result of ether- 
ization alone. In certain very rare instances death had 
taken place after abdominal operations without any 
pathological cause whatever. In one illustrative case, 
after an aseptic, though difficult and bloody operation, 
the patient presented the typical clinical picture of fatal 
general peritonitis. The pathologist at the Massachusetts 
General Hospital could find no evidence whatever of bac- 
terial infection at the autopsy or in the laboratory. That 
there was an infection the essayist had no doubt, but by 
a germ which produced none of the usual physical signs 
of sepsis, which failed to grow on ordinary media, and 



which was not stained by the ordinary media. Un- 
controllable capillary oozing might be regarded as un- 
avoidable, and beyond power of prediction only when it 
took place after careful examination of the blood with 
reference to its coagulability, and other possible evidences 
of a tendency to bleed. Capillary hemorrhage from 
jaundice might be in certain instances uncontrollable. It 
could be regarded as uncontrollable only when operation 
must be performed in spite of the evidence of the tendency 
to hemorrhage. The coagulation tumor did not reason- 
ably assure safety against bleeding, even if it was shown 
experimentally to be brief. The author's last fatal 
hemorrhage in jaundice took place from the capillaries of 
the lesser cur\'ature of the stomach, remote from the 
operation area, though the blood coagulation tumor was 
perfectly satisfactory. In another case a fatal and uncon- 
trollable capillary ooze followed an operation upon the 
common duct after a year of biliary fistula. In this case 
no bile had entered the intestine during the existence of 
the biliary fistula. The most frequent of such rare 
calamities was sudden death from pulmonary embolism. 
The cause of death could be neither predicted nor pre- 
vented. It occurred with no peritonitis. The probability 
of embolism being the result of a phlebitis was considered. 
In the author's experience, in a considerable number of 
deaths there were no premonitorj' symptoms whatever, 
while in cases of phlebitis, definite and unmistakable, no 
such accident occurred. Pulmonary embolism had been 
observed most frequently after pelvic operations upon 
women with large uterine or ovarian tumors, and espe- 
cially in women lone exsanguinated by fibroids. 

Papillary Cysts and Papillary Tumors of the Ovaries. 
— Dr. S.'^MUEL Pozzi of Paris, France, read a paper 
on this subject, in which he summarized as follows: (i) 
Papillary tumors of the ovary, cystic or solid, must not 
be considered as always malignant. Some of these tumors 
never undergo malignant degeneration, and do not relapse 
after removal. Some relapse after a long time, and 
locally without metastases. (2) A careful distinction 
must be made between carcinomatous generalization, 
which takes place through the lymphatics and blood-vessels, 
and simple grafts which result from contact, or from the 
growing over the peritoneum of detached papillary vegeta- 
tions of the o\-ary. This process is benign and can be 
compared to the grafting of papillomas and warts of the 
skin. (3) Some of the tumors undergo a malignant de- 
generation which is for some time limited, but may later 
extend all over the mass, and which at last brings on 
a real generalization with cancer metastases. Before 
this last period, and at the outset of the malignant trans- 
formation, it is quite impossible to discern it with the 
naked eye, and microscopical investigations are needed. 
The prognosis is always uncertain in operations of this 
kind before a thorough pathological examination. Even 
such examination may lead to misinterpretation, if it 
has not been carried all over the tumor, for the degenera- 
tion may be limited to a small part of the growth. (4) 
When positive symptoms of malignancy are absent, 
such as cancerous cachexia or visceral metastases, opera- 
tors must always treat these tumors as if they were benign, 
and proceed to remove, to the largest extent possible, the 
neoplasm. The disseminated growths, or even small 
parts of the papillary tumor detached and lost in the 
peritoneal cavity may disappear. In other cases they 
may be the origin of local recurrence. But these re- 
lapses can be treated successfully by secondary opera- 
tions. (5) Frequency of successive invasion of both 
ovaries by papillary tumors, furnishes an indication to 
remove the adncxa on both sides, even if one is still 
healthy, at least in women who are near the change of 
life. In young women it would be better to preserve 
a non-diseased ovary. (6) In bilateral papillary tumors 
the operative technique can be greatly improved by 
performing partial or total hysterectomy, according to 
the case. (7) Drainage is not necessary when the cysts 



July 9, 1904] 



MEDICAL RECORD. 



75 



ha\-e no outside vegetations, and when there is no ascites. 
But in case ascites exists for some time, it would be well 
to drain the peritoneal ca\4ty. Incomplete removal, 
or even an exploratory section, in unoperable cases, is 
often accompanied by a real diminution of ascites, with 
local and general improvement. " 

Ankylosis Treated by Arthroplasty. — Dr. John B. 
MuRPHV of Chicago spoke on this subject. He men- 
tioned three types of ankj-losis, namely, ankylosis from 
periarthritis; ankylosis from capsular lesions, and bony 
ankylosis. Bony ankylosis could be reUeved. Tissue 
could be interposed to prevent reestablishment of bony 
union, and with the recognition of the changes which 
occurred in fat close to the aponeurosis, a joint could be 
produced with a serous-secreting surface. His experi- 
mental work had shown that after the remo\-al of the 
hip-joint in a dog, cartilage, s^-no^•ial membrane, and 
the articular surfaces in their entirety, with replacement 
of tissue in the acetabulum, and replacement of bone 
again, he had produced a typical sii'no\-ial membrane 
in the sense of a hygroma. In the production of hygroma 
pressure on fatty tissue had a tendency to bring about 
a coalescence of the small fatty capsules. The shaft 
of these capsules produced a serous secretion, and there 
was developed a condition which was seen in housemaid's 
knee, over the trochanter of the boilermaker, and over 
the wrist of the stonecutter. A serous-secreting sur- 
face was brought about. This coxild be done in a joint. 
The surgeon could restore joints to practically their 
normal condition. The first case he reported was one 
of bullet wound of the abdomen. The bullet passed 
through the abdomen a Uttle to the right of the median 
line, passed across the abdomen, perforated the intestine 
eight times, fractured the head of the femur, lodged in a 
pocket, remained there, worked its way out through 
ulceration, and was finally voided through the intestine. 
The wounds in the intestine were sewed up, and the patient 
recovered, with a sinus. The speaker saw the patient 
with ankylosis of the leg at right angles. He passed 
around a skiagraph which showed bony union. After 
removing the head of the femur transperitoneally, curet- 
ting and remo\'ing the bony debris from the ilium, the 
wound was allowed to heal, and a plan was devised for 
the restoration of the joint and the relief of deformity. 
He decided that it was necessary, first, to expose the 
joint and to secure bony tissue for the new head. Second, 
it was necessary to interpose between the fragments not 
only muscle, but fascia, covered with fatty tissue, be- 
cause the fatty tissue here, subject to pressure, like the 
fascia lata of the trochanter, formed hygromata. A 
U-shaped flap was made, carrying w^ith it fascia lata 
and all the superficial tissue and skin, then the joint 
sawed from around the trochanter major. None of the 
muscles was divided. A circular chisel was used to 
chisel out the bone in all directions, and with the assis- 
tance and leverage of the femur and chisel a fracture 
was produced at the base of the cavity, and the head, 
which was new bone formation, as the original head was 
removed, was thrown out in connection with the neck, 
rounded off -nith bone-cutting forceps, and curette used 
to enlarge the cavity. The next step of the operation 
was to separate the fascia lata with its fat and a few 
fibers of the gluteus muscle; a flap was swting in behind 
the muscular attachments, and the trochanter major put 
in around the head of the femiir and sewed to the nesk. 
The neck was made short to prevent reunion of the 
fibrous portion of the capsule which remained, because 
if the capsule remained in its fixed position, the ankylosis 
would continue, and this was one of the practical points 
he derived from this particular case. The trochanter 
major was sutured to the neck, the head replaced, the 
trochanter major roiuided off, the flap turned down and 
the wound drained. The result of the operation was 
ideal. Dr. Murphj' passed around a photograph showing 
the patient as he stood ia the erect position, and the 



degree of fle.xion obtained at the end of four months 
after operation. The patient now had perfect motion and 
flexion. He mentioned other cases on which he had 
operated by this method, with gratifying results. The 
method was largely intended for the treatment of joints 
^vith ankylosis. 

Ifew Aids in Diagnosis of Surgical Diseases of the Kidney. 

— Dr. A. T. C.^BOT of Boston read a paper on this sub- 
ject. His conclusion from the experience he had had and 
from his study of the work of others, were that ^segregation 
of the tuines was of great use sometimes in deciding the 
question as to which kidney was diseased, or even as to 
which was most affected. Determination of the functional 
capacity of the kidney by testing the elimination through 
it might be of assistance by adding strength to what evi- 
dence we had, but would be often misleading if too im- 
plicith' relied upon for deciding operative measiu-es. 

Report of a Case of Acute Pancreatitis Associated with 
Gallstones. — Dr. J.\mes Bell of Montreal said that the 
demonstrated facts in his case were: (i) That in March, 
1898. there were all the characteristic lesions, as well 
as the signs and symptoms of acute pancreatitis, and at 
the same time an apparently quite healthy liver and gall 
passage, -with two or three stones in the gall-bladder. 
(2) That all signs and symptoms of pancreatitis dis- 
appeared, the patient recovering, and considering himself 
quite well until nearly two years later, when a new train of 
symptoms developed, which were characteristically those 
produced by gallstones. (3) Three years after the attack 
of acute pancreatitis it was demonstrated that while 
extensive and serious pathological changes had taken 
place in the gall-bladder and bile ducts, all local signs of 
acute pancreatitis had during the same period of time 
entirely disappeared (subperitoneal fat necrosis, and 
swelling of the pancreas) ; that was to say, that acute 
pancreatitis developed before there were any pathological 
changes in the gall-bladder and bile ducts, and that while 
such changes were taking place the pancreatitis was 
recovered from. These facts would seem to be at variance 
with modem views of the etiology of acute pancreatitis, 
which tended to attribute this condition in a general way 
to a pathological change in the common bile duct due 
to the passage of gallstones from the gall-bladder to the 
intestine. 

The Treatment of Congenital Cleft Palate : A Plea for 
Operations in Early Infancy. — Dr. Trvm.^.n- W. Brophv of 

Chicago read a paper, by invitation, on this subject. 
After referring to the work of Lamonier, Kirmisson, Roux. 
and many others in this field, the essayist stated that 
after having studied carefully the literature and the 
methods pursued by other operators, he had endeavored 
to overcome the objections and to avoid the difficulties 
with which the older surgeons contended, and he was 
satisfied that the most desirable time to select for operating 
was within three months after birth. In operating at 
that time one was able to secure more satisfactory results 
than later in life, and avoided the objections usually 
raised by surgical wrisers. He believed in operating at 
as early an age as practicable after birth, preferably 
within three months, and his experience of twenty years 
in operations performed for the closure of cleft palate, 
at from ten days to fifty years of age, including 927 opera- 
tions, had more and more justified the practice. Among 
the advantages mentioned in favor of early operations, 
were the following: Surgical shock was less because the 
nervous system of a young child was not well developed, 
and it was not, therefore, capable of receiving the same 
impressions that it would later in life. Furthermore, 
young children usually reacted better. All mental appre- 
hensions were eliminated, and alarm and dread were among 
the most powerful factors in producing shock. FoUo^^ing 
early operations there was much less deformity, for all the 
tissues, bony as well as soft, developed naturally and 
according to accepted types. When the operation was 



76 



MEDICAL RECORD. 



[July 9, 1904 



postponed for a few years, it was very difficult to secure 
as good results. When the operation was made in early 
infancy, the parts were sufficiently developed to give 
possibility for normal speech when the child had reached 
a speaking age. The author described his method of 
operating on cleft palate in detail, a description of which 
has heretofore been published in both dental and medical 
journals. In conclusion, the author stated that if opera- 
tions were made later in life, the patient should be placed 
under the instruction of one \\-ho had the perseverance, 
the ability, and the patience to teach him how to over- 
come the defective speech whifh he had acquired. 

The Evolution of Surgery. — Dr. J. Ewing Mears of 
Philadelphia read a scholarly paper with this title. He 
divided this unfolding of surgery into three periods of 
time: (i) That which extended from the beginning to the 
time of Ambroise Par^, 1517-1519; (2) the use by Johns 
Collins Warren (1846) of ether as an anasthetic in surgical 
operations, and (3) the disco^'ery and introduction into 
general use by Sir Joseph Lister (1860-1875) of the anti- 
septic treatment of wounds. Each period was taken up 
and considered in a masterly manner. 

A Mechanical Device for Gastric and Intestinal Anasto- 
mosis. — Dr. P. B. H.\RRi.VGTON- of Boston described a ring 
for the purpose of intestinal anastomosis. The advan- 
tages of this ring were stated as follows: (i) Safety and 
speed. A complete resection and suture can be easily 
done in fifteen minutes, and with as great speed as by any 
more protracted method. (2) Cleanliness. Assisted by 
clamps, the purse-string sutures prevent even a mucous 
ooze, while the continuous stitch is being placed. (3) 
The intestinal suture is more easily done over the ring 
than without it. (4) It is safe to use a single laj-er of 
continuous stitches, since the ring allows a perfect approx- 
imation to be made, and afterward protects the suture 
until adhesions have formed. (5) The handle is very 
useful for holding the intestines in convenient positions 
for sutures. (6) It is not necessary to sew up any of the 
layers, since a study of specimens from animals and human 
beings shows that the mucous membrane will slough in 
any case, and that repair is more rapid when the mucous 
membrane is not sutured. (7) The presence of the ring 
guarantees a free opening at the site of operation. (8) 
In case the continuous stitch should be improperly applied, 
the weak spots are protected by the ring itself for at 
least three days, until the ring breaks down. This allows 
strong adhesions to form. (9) After operation the ring 
holds the suture immovable, and acts like a splint. The 
weights of the individual segments of the ring vary, as 
most other appliances of a similar nature. 

Dr. J. W. Dr.^per Mairy of New York City, by invita- 
tion, stated that instead of using the elastic ligatiu-e at the 
Laboratory of Columbia University, they had been em- 
ploying twine. The specimen which he exhibited was 
made with the elastic ligature put in by a square knot, 
thus differing from Dr. McGraw's technique; but for the 
last three months he had obtained as good results by using 
simple twine instead of the elastic ligature. The method 
of introducing the twine might follow the McGraw tech- 
nique, although the triangular stitch possessed a very 
distinct advantage over it. This stitch punched out as 
much tissue as might have been included in the triangle. 
As to time, it would cvit through in less than three and a 
half days. It must be very tightly tied. This was the 
sole requirement to success. Dr. Maury demonstrated on 
a chart the technique of introducing the triangular stitch, 
and stated that he included about one-third the circum- 
ference of the gut in the stitch. The gastric triangle 
should, as a rule, be made larger than the intestinal. He 
then passed around photographs of specimens made by 
this method, and a preparation from the gut of a pig. 
which demonstrated how free an anastomosis might be 
established. He also showed a number of circular bits of 
twine, which had been used in executing the technique. 



They had cut the triangle out and had been recovered 
after their passage through the rectum. 

The Subtle Force of Radium. — Dr. Robert .\bbe of 
New York City narrated his experience with this new- 
therapeutic agent, saying that radium had a powerful and 
seemingly beneficial effect upon cases of recmrent car- 
cinoma. Cases were cited in point. He mentioned one 
case of virxUent, typical carcinoma of the scirrhous type, in 
which the carcinomatous nodules were reduced to one- 
third their original size by radiomization. The agent had 
been used in cases of lupus, superficial epitheliomata. 
carcinoma, rodent ulcer, superficial sarcomas, etc. In 
cases of superficial recurrent carcinoma of the breast, if 
radium was applied to the diseased area for a considerable 
time, sav an hour, then the patient permitted to go. and 
the agent reapplied at intervals of two or three days, the 
carcinomatous masses would melt away in some cases. 
In other instances, these masses would disappear under 
the use of the «-ray, still others wotUd resist the action of 
the a:-ray, while radium would act beneficially. Radium 
had an extraordinary power in inhibiting the growth of 
mslignant cells in some cases. 

Dr. W. W. Keen of Philadelphia said that one positive 
fact was worth a dozen negative ones. One could not get 
away from the facts presented by Dr. Abb^ and others in 
regard to the use of radium. On the other hand, members 
of the profession ought to report their negative as well as 
positive results. He had had an experience now covering 
twentv-two cases in which radium was used. Whether 
his results were due to the quality of radium, to a differ- 
ence in the character of the growths, to the method of 
using it, or what not, he did not know. But to sum up 
his experience, in not one single case had there been the 
slightest benefit, except in one feature, and that was as to 
pain. Unquestionably in cases of carcinoma, patients had 
suffered less and in a large number pain had disappeared. 
In one case of tic douloureux of the lower jaw the man 
left the hospital at the end of a month practicalh- well. 
In the course of six or eight weeks the patient wrote him 
that he had had a recurrence of the pain. Dr. Keen 
wrote him to return for treatment, but had heard nothing 
from him since, and whether the pain had disappeared or 
not, he did not know. He had used the German instead 
of the French radium. Some of his specimens had varied 
from 17.000 radio-activity up to a larger radio-activity, 
until finally he was able to obtain one specimen with 
1,800,000 radio-activity. He regretted to say that his 
experience had not been satisfactory with the use of 
radium. 

Gastrostomy in CEsophageal Stricture. — Dr. James H. 
Dunn of Minneapolis, Minn., said that cicatricial stricture 
was the most serious benign affection of the oesophagus. 
Retrograde and through and through treatment of certain 
cesophageal strictures had been recognized since the 
operation of Loretta, in 1883; but discoveries and im- 
provements in operative technique had finally completely 
changed the situation, leaving surgeons in a position to 
approach one of these cases with a very safe and certain 
technique, and to fill the following indications: (i) A 
gastric fistula which would not leak, and close spontane- 
ously. (2) To get a reliable guide through the canal with 
perfect safety and certainty. (3) To divide the scar 
tissue sufficiently. (4) Relative asepsis and rest of the 
wounded surface, prevention of stagnation of food, and 
for' a time the irritation of its passage. The value of the 
Stamm-Keder form of gastrostomy was generally under- 
stood, but it was only when one fully appreciated by 
experience that any cesophageal stricture might be com- 
manded perfectly and with precision by means now at 
hand, through very small gastric fistula;, even the size of 
a No. 20 French catheter or less, that all the advantages 
of the method appeared. The steps of the operation were 
described. A modification of Dunham's wire and spindle 
bougies was suggested as somewhat simpler and more 



July 9, 1904] 



MEDICAL RECORD. 



77 



handy. The writer had not found it necessary to use 
guards to prevent the epiglottis and stomach fistula from 
chafing. By this plan but one anaesthesia was necessary 
in each case. The fistulse had not leaked and had promptly 
healed spontaneously. A caliber admitting of free swal- 
lowing was reached in from one to three weeks, and an 
appro.ximately normal caliber achieved in from two to 
four months, after which the tendency to relax had been 
imperceptible. The author reported three very severe 
cases, one in a girl, aged nineteen, following typhoid 
ulceration, and two in children, aged nine and two years, 
from the ingestion of concentrated lye. Repeated at- 
tempts had failed to reach the stomach through the mouth 
in all these cases. 

The Bridging of Nerve Defects. — Dr. Chas. A. Powers 
of Denver, Col., said the difficulties in the way of prepar- 
ing a satisfactory paper on this subject were due to the 
indefinite manner in which nerve suture was treated in 
medical literature, to the widely scattered and badly 
indexed material collected and published by Chipault, to 
the fact that much of the material in the literature of the 
subject described operations upon animals, that a large 
proportion of operative cases in men were reported before 
the establishment of a permanent result, and to the fact 
that in case of failure, it was not easy to say that a given 
bad result was due to a faulty technique in the operation 
itself, as a similar result might have followed direct suture 
of the fragments. The author reported in detail a per- 
sonal case of transplantation of four inches of the great 
sciatic of a dog to the external popliteal of a man. Union 
was prompt. The fragments stayed in place, and the 
immediate result seemed to be encouraging, but the 
ultimate result was a total failure. Examination and 
report were made eight years after operation. Cases of 
the bridging of nerve defects gathered from literature 
showed the following number : Grafting, 2 2 ; flap opera- 
tions, 11; implantations (anastomosis), 10; resection of 
bone, 7; suture i distance, 3; tubulization, i. Analysis 
of these cases showed that grafting was a failure and 
should be discarded, while the results in flap operations 
and anastomosis were about the same, something over 
50 per cent, of the cases being successful. While these 
last operations were not very promising, they seemed at 
present to be the methods of choice. 

Final Results in Secondary Suture of Nerves. — Dr. 
Emmet Rixford of San Francisco, Cal , reported three 
cases of secondary nerve suture, of the ulnar at the wrist, 
of the musculospiral and the facial at the stylomastoid 
foramen, six, four, and two years respectively after opera- 
tion. In the first case the atrophic thenar, hypothenar, 
and interosseous muscles regained their normal volume 
and function, save in so far as motion of the fingers was 
limited by adhesions, the result of fixation and chronic 
arthritis. In the second case the musculospiral nerve 
was sutured eight weeks after rupture, complicating a 
fracture of the hiunerus. A defect of three centimeters 
was overcome by shortening the hiunerus that amount 
and the result after four years was complete motor and 
sensory restoration of function, with slight atrophy, 
one-half centimeter difference in circumference in the 
forearms. In the third case the facial nerve was severed 
by a narrow tooth beneath the mastoid process. Com- 
plete facial paralysis. Suture at eight weeks after the 
injury. In order to secure tissue for the sutures, the 
mastoid process was cut away with the surgical engine, 
and the external wall of the fallopian canal removed for 
five or six millimeters. Result after two years: Face 
symmetrical, when in repose; eye closes in sleep; may 
be closed at will; angle of mouth, tip of nose and chin 
can be drawn to the paralyzed side. The prognosis 
in secondary suture was but little, if at all, inferior to the 
prognosis in primary suture. In the presence of infection, 
secondary suture was preferable to primary. All scar 
tissue should be removed, including the whole of terminal 
neuroma of central segment, the nerve ends united by 



absorbable suture with the least possible" traumatism. 
Defects, if not too great, could be overcome by stretching 
which should be done before section of the ner\'e ends or 
by shortening of the bone in certain cases. 

Primary Carcinoma of the Liver. — Dr. Leonard Free- 
man of Denver, Col., reported a case of primary car- 
cinoma of the liver on which he had operated, with 
freedom from recurrence at the end of sixteen months. 
After dealing with the different methods of operating, 
he reported his case in detail. 

Thyroidectomy for Exophthalmic Goiter. — Dr. Chas. 
H. Mayo of Rochester, Minn., in a paper with this title, 
said the subject of goiter was still imsettled, both as 
regards etiology and treatment, although hundreds of 
articles had been written upon it. Recent investiga- 
tions concerning the lymphatic system and ductless 
glands rendered the subject very interesting at this time. 
E.xophthalmic goiter was a distinct type, with many 
symptoms, involving the mental, muscular, digestive, and 
circulatory fimctions, the most common being the tachy- 
cardia without other cause. While the mortality was 
comparatively high, it was among those cases which had 
already run the gauntlet of most known remedies for the 
disease, and should not be entirely laid at the sur- 
geon's door. The surgical methods were exothyropexy 
ligation of the thyroid arteries, removal of the cervical 
sympathetic ganglia, thyroidectomy, and the physio- 
logical effect of operations upon other regions. The 
author and his brother had operated upon 130 goiters; 
40 were of the exophthalmic type, and of these, 6 died, 
as the restilt of the operation. In the first 15, there were 
four deaths due to lack of judgment in accepting almost 
moribimd cases. There were but two deaths in the last 
2 5 cases. Very severe cases were subjected to ^-ray ex- 
posures, and with belladonna given internally for a few 
days or weeks previous to operation. Their own cases 
showed marked improvement in all who survived the 
operation. Of these 50 per cent, made a very early 
recoverj', especially of the severe symptoms, such as 
tachycardia, nervousness, and tremor; 25 per cent, did 
so after several months, and 25 per cent, were improved, 
yet suffered from irregular recurrence of some of the 
major symptoms. 

Gallstones in the Common Bile Duct. — Dr. S. H. Weeks 
of Portland, Me., read a paper on this subject, in which 
he considered the diagnosis and prognosis, and said that 
impaction of a gallstone in the common duct rarely 
caused marked distention of the gall-bladder; it caused 
dilatation of the branches of the hepatic duct, and might 
resxilt in pronounced and even fatal jaundice. Obstruc- 
tion of the common duct was always accompanied by 
jaundice. The jaundice was intermittent or remittent 
where the calculus floated in an enlargement of the com- 
mon duct, because the system would eliminate the color- 
ing matter of the bile in the inter\-aL The cystic duct 
might be occluded, and give rise to grave sj-mptoms, 
without there being any trace of jaundice or any history 
of biliary colic. Jaundice with distended gall-bladder 
not due to gallstones was presumptive evidence of malig- 
nant disease. Jaundice without distended gall-bladder 
favored the diagnosis of cholelithiasis. The treatment 
was necessarily surgical. 

Dr. A. P. Jones of Omaha, Neb., read a paper on 
"Primary Splenomegaly, Accessory Spleens, Splenec- 
tomy, " and reported an interesting case. 

Dr. S. J. MiXTER of Boston, reported a case in which 
he removed the upper jaw for extensive osteosarcoma, 
with an excellent result, considering the formidability of 
the operation. 

Dr. Rudolph Matas of New Orleans, La., exhibited 
and described a new interdental splint which he had 
recently devised for the treatment of fractures of the 
jaw, particularly the lower jaw, without bandages. 

Dr. Alexander Hugh Ferguson of Chicago exhibited 
a patient upon whom he had performed renal decap- 



78 



MEDICAL RECORD. 



[July g, 1904 



sulation for chronic interstitial nephritis three and a 
half months ago, with an excellent result. 

Officers. — The following officers were elected: Presi- 
dent, Dr. Geo. Ben. Johnston of Richmond, Va. ; Vice- 
Presidents, Dr. Emmet Rixford of San Francisco, Cal., 
and Dr. James Bell of Montreal ; Secretary, Dr. Dudley P. 
Allen of Cleveland, Ohio; Treasurer, Dr. Geo. R. Fowler of 
Brooklyn, N. Y.; Recorder, Dr. Richard H. Harte of 
Philadelphia; Counselor, Dr. N. P. Dandridge of Cincin- 
nati, Ohio. 

San Francisco, Cal., was selected as the place for hold- 
ing the -next meeting, the date to be decided by the 
officers and committee of arrangements. 

NEW YORK ACADEMY OF MEDICINE. 

SECTION ON OBSTETRICS .\ND GYNECOLOGY. 

Stated Meeting, Held April 28, 1904. 
Dr. A. Palmer Dudley, Chairman. 
Occiput Posterior Positions of the Vertex. — Dr. John O. 
PoLAK of Brooklyn read this paper. (See page 55_) 

Occiput Posterior Positions. — Dr. S. Marx read this 
paper. (See page 54.) 

Dr. Malcolm McLean continued the discussion and 
said that a great deal had been written on this subject, but 
unfortunately there seemed to be an extension of words 
without conveying much clear and definite teaching, but 
the paper of Dr. Polak was the best he had ever heard on 
the subject of occiput posterior positions. 

In occiput posterior positions one of the greatest dangers 
encountered was from the injudicious interference with 
forceps. The majority of these cases, if left alone, he said 
would rotate to the front and become practically normal ; 
but, unfortunately, such labors are very tedious, slow, and 
uncertain. He had never yet seen a normally acting 
uterus in occiput posterior positions; therefore, it had 
been suggested that some malposition of the foetus causes 
it to act in an irritable way, with short pains, etc., and the 
short, inefficient pains, or contractions, kept up an unusual 
number of hours which was so trying to the patient, to 
both her mental and physical condition, to the family and 
to the attending phycisian. Such an existing condition 
often drove the physician to performing operations in an 
improper manner and at an improper time. This was his 
experience in the average run of these cases in the average 
physicians' hands. The consequence was that when the 
occiput was at the right sacroiliac synchondrosis, the 
forceps would be placed to the sides of the child's head 
before a correct diagnosis had been made. This he had 
seen done time and again, and the result invariably 
was that as soon as the forceps was applied wth the view 
of bringing what was supposed to be the high occiput on 
the left, down and spirally to the front, an obstruction 
impossible to pass was made mechanically. The result 
was that the women were very much inj\u-ed by the 
operation, and it was only after the forceps had slipped 
after many wretched and repeated attempts had been 
made, that it became apparent that a correct diagnosis 
of the position had better be made. Then it was to late 
to do much. The position should have been discovered 
at the earliest moment and then the methods tried that 
were advocated by Dr. Polak. 

Dr. McLean said that one of the greatest difficulties 
encountered in occipxit posterior positions was the rotation 
of the body of the child in order to secure proper anterior 
position of the occiput. After getting the occiput in the 
anterior plane it should be kept there; it was easy to get 
it to the front but very difficult to keep it there. In many 
of the cases of occiput posterior positions, manual inter- 
ference was required, because the head was in such a rela- 
tion to the peh-is that it tended to maintain its posterior 
position; it was not the result of improper flexion only, 
but there was a positive tendency of the occiput to remain 
in the posterior position. He had again and again seen 
attempts made by different methods to bring the occiput 



to the right anterior plane, holding the occiput there until 
a pain brought it down, then forceps applied and there 
resulted the same old story, the occiput was on the pos- 
terior of convex side of the forceps. Now, why? In a 
great many cases the body of the child influences the head, 
and, in many cases, this influence was produced by the 
cord being passed around the shoulder and neck of the 
infant. Therefore, when attempts are directed to bring 
the shoulders around they will not come beyond a certain 
point, they will just describe a certain part of the arc of a 
circle and no more. Continual attempts to produce this 
mechanical rotation produces torsion of the spine of the 
child, because of the fixation of the body. The moment 
that difficulty of this kind is encountered he caused the 
occiput to rotate all the way around to the left anterior 
and this with perfect ease. He had gone to see cases pre- 
pared to do podalic version and had found the cord, in 
some cases, was only six inches in length from the placenta 
to the shoulders of the child. The cord was shortened 
by the position of the child, and in such cases he said it 
was much easier to take the long circuit and bring the 
occiput to the left anterior plane rather than to the right; 
thus bringing the body of the child right around and 
unwinding the involved cord which had acted as a check 
to rotation in the opposite direction to the right. 

Dr. Egbert H. Grandin said that about ten years ago, 
at a meeting of the American Gynecological Society, held 
in Brooklyn, he read a paper before an audience com- 
posed of men from all over the United States and dealt 
with the same topic, occiput posterior positions. At that 
time he had charge of two maternity services, and it had 
then been his experience to see sixteen cases of occiput 
posterior positions within six weeks. He made that 
statement and surprise was expressed at the frequency of 
the position. He said he was glad to know that the 
prevalence of this position was now clearly recognized. 
To his mind it was the most common position which 
called for interference in the ordinary type of obstetrics. 
Nowadaj-s he did not do much obstetrics, but in 95 per 
cent, of the cases in which he was called in consultation he 
felt pretty sure that he was being called to see cases of 
occiput posterior positions, as a rule in the cavity or 
impacted at the outlet. The conclusion which he reached 
ten or twelve years ago had suffered but very little modifi- 
cation as the result of a greater experience. As a rule, 
occiput posterior positions occurred because there was 
some disproportion between the presenting part and the 
pelvis, either the pelvis being too small or the fetal head 
too large. 

Dr. Grandin said that he failed to see how the "new 
school" could recognize an occiput posterior at the brim 
or in the cavity, because this school tried to tell us not to 
make internal examinations but to rely entirely upon 
external manipulations for diagnosis. He did not think 
the average man could recognize such malpositions by 
external examination. With the occiput posterior and at 
the brim, with the membranes unruptured, with the cervix 
dilated or dilatable, it was his custom to do a podalic 
version followed by quick extraction of the child. In that 
class of cases ■n-ith membranes ruptured and the head 
descended posteriorly into the cavity, he asked what 
should be the rule of procedure? It was in this class of 
cases that the reader of the paper used axis traction. 
Dr. Grandin said that if it was simply a question of merely 
rotating the head he would agree with the method ad- 
vocated but it was not simply a question of rotating the 
head. The head could be rotated through a certain 
circuit without damaging the fcetus, but one could not 
rotate it a great ways without killing the child because 
the trunk of the child would not follow the head in its 
rotation. Therefore, he thought the method advocated 
was not rational. The object should not be rotation of 
the head but rotation of the body of the child and here 
was where the point raised by Dr. McLean entered in; 
rotate both head and body and while the patient was under 



July 9, 1904] 



MEDICAL RECORD. 



79 



deep surgical anaesthesia; the entire hand in the vagina 
should grasp, not the head, but the shoulders of the child 
and rotate the foetus in the direction it went the most 
easily. If one tried to rotate it to the left and found it 
would not go it meant that the cord was interfering and 
then rotation should be made in the other direction. If 
the head was found at the outlet and impacted he said 
there was but one thing to do in the interest of the mother, 
operate upon the child. Of late years he said he had 
learned more about this class. Dr. Isaac Taylor, two or 
three months before his death, asked Dr. Grandin to 
select from his stock of instraments what he desired and 
then, after his death, to give the balance to the Maternity 
Hospital. Dr. Grandin selected a short-handled forceps, 
which he carried nowadays with his action traction forceps 
and angiotribe. If the head was impacted at the outlet, 
with a living child, he applied these short-handled forceps 
in the inverted sense and so secured flexion; flexion once 
secured one could then deliver the child. Get flexion and 
deliver, although with loss of integrity of the pelvic floor. 
Dr. Grandin said that ten years ago he was severely 
criticised when he advocated manual manipulation at the 
brim; now he advocated version. 

Dr. Joseph Brown Cooke agreed with all that Dr. 
Grandin had said and believed that occipitoposterior 
positions were much more common than generally sup- 
posed. It was an easy presentation to diagnose by 
abdominal palpation. In his experience he had found the 
postural method to be of but little value because the 
rotation of the head was almost always to the front in 
spite of it. He believed it to be inexcusable for anyone to 
attempt to apply the forceps without a definite knowledge 
of the presentation. Before the application of the forceps 
there should be a dilated or a dilatable cervix and the 
patient should be completely under the influence of the 
anaesthetic. 

Dr. Robert A. Murray referred to an unusual number 
of cases of occipitoposterior presentations that had 
occurred at the Maternity Hospital between the years 
1890 and 1893, and he thought this was due to the fact that 
there were so many women of foreign birth and with 
deformed pelves. Whenever such a position occurred he 
said that it was necessary to determine why. It was, as a 
rule, not due to the size of the child but to some malforma- 
tion of the pelvis. One should know exactly just what the 
size of the child's head was and its relation to the pel»is, 
and if this could not be done readily then the patient 
should be placed under complete anesthesia and the 
hand introduced into the pelvis for a more thorough ex- 
amination. The mortality in these cases he considered to 
be very great, and was apt to be complicated with em- 
barrassing circumstances, such as lacerations, eclampsia, 
prolonged labors, bleeding, etc. He believed that many 
of these cases should be treated by version. In most of 
the textbooks it was stated that, in the mechanism of 
occipitoposterior positions, the head instead of extending 
was forced down to the floor of the pelvis and gets imder 
the spine of the ischium and then commences to rotate, 
i.e. cannot rotate until it gets beneath that spine. Dr. 
Murray said that it could if one endeavored to correct this 
extension by efforts at flexion, pushing up the frontal 
portion and so allow the forehead to come do-nm. He said 
that out of one hundred cases of occipitoposterior posi- 
tions four or five w-ould rotate into the hollow of the 
sacrum. In these cases it was very difficult to apply the 
forceps; to apply them transversely was almost an im- 
possibility. One could not pull the head straight down 
because of the great damage done; the child might be 
killed and the mother greatly injured. 

During the years 1890 and 1893 there were 957 cases; 
among these there were 119 low forceps operations and 12 
high forceps. In 9 labor was induced, in 4 there was 
eclampsia, in 6 hemorrhage, in 28 version, in i caesarean 
section was performed, in i laparotomy, in 7 craniotomy, 
and in 7 episiotomy. Among these cases there were 4 



deaths, 3 from eclampsia, and i from ruptured uterus. 
There were no deaths due to the use of forceps or ta 
version. 

Dr. A. Palmer Dudley said that his experience in these 
cases had been purely surgical. He said he had never 
done a craniotomy and had had one case of ruptured 
uterus. 

Dr. S. Marx said he was not so much afraid of occipito- 
posterior positions as he once was. The early operative 
treatment of these cases he believed to be a mistake. 
When there was occasion to operate one should operate 
quickly and before the membranes ruptured if possible. 
He did not know how many of occipitoposterior presen- 
tation he had seen but in not one of them had the mem- 
branes not ruptured early. If the membranes had 
ruptured he would hesitate to interfere because in 90 per 
cent, of the cases rotation would occur spontaneously 
during the course of the labor. Manual rectification had 
not been successful with him. If he should find it neces- 
sary to go into the uterus and if he was in a position to do 
version he said he would do an elective version. If this 
was undertaken late in the progress of labor it would be a 
difficult thing to do, and then it might be a better pro- 
cedure deliberately to perforate the child's head. Dr. 
Grandin stated that by rotation with the axis traction 
forceps, it would wring the child's neck; he asked if the 
same thing would not occur with the hand in the uterus 
and attempts made at rotation. 

Dr. Robert A. Murray said that when he made the 
statement regarding the correction of the position of the 
child's head, he meant that the hand should be passed up 
to grasp the shoulders and efforts made at rotation of the 
shoulders as well as of the head. 

Dr. Marx said that he did not believe the question of 
contracted pelvis entered at all into the consideration of 
this subject any more than the consideration of the con- 
dition of the child's head in its relation to the spinal 
column. If the child was in the dolichocephalic condition 
in position with the spinal column in the middle part of 
the base of the skull there wovild be a question whether 
the head would extend or take a position of semi-flexion. 
The relation of the head to the spinal colume should be 
kept in mind. The moment it struck the superior plane 
of the pelvis flexion occurred and, in the mechanism, 
more had to do with the condition of the child's head. 
The question arose as to what constituted a "contracted 
pelvis." He did not know unless it meant that the head 
was too big for the pelvis. 

With regard to making a diagnosis of occipitoposterior 
positions by external manipulation alone he agreed with 
Dr. Grandin in what he said in reference to the so-called 
"new school." This new school made the diagnosis so 
easily because in 95 per cent, of all cases the head presents 
and, when certain things operated, it was onlj' necessary" 
to say "occipitoposterior position" and you would 
almost always be correct. He said that he examined as 
often as he deemed it necessary and guided the head with 
his hand in the vagina around to the anterior. 

With regard to the rotary axis traction he said he was 
not often compelled to use it. In spite of what Dr. 
Grandin said in criticism of it he believed that Dr. Grandin 
would use it before he died. 

It was rather interesting for him to hear Dr. Murray 
speak of the cases occurring in the early go's because those 
cases occurred while he was assistant surgeon to the 
Maternity Hospital and were his. Dr. Marx's, owti work. 
In a great many cases he -believed that perforation should 
be the method of election. During every year he had 
about one dozen perforations to do in his consultation 
practice. 

Dr. George Tucker Harrison took issue ■s\dth those 
who said the}- should make as many examinations as they 
choose. He believed the fewer examinations made the 
better, because of the difficulty of getting the hand per- 
fectly aseptic. He did not apply forceps to correct 



8o 



MEDICAL RECORD. 



[July 9, 1904 



positions of the head; if the head was high he preferred 
podalic version. With this method he had satisfactory 
results and, therefore, did not care to change. 

Dr. John O. Polak closed the discussion and said that 
he believed all were in accord with the position assumed 
by him, i.e. in cases of head above the brim, treat by 
version ; and in those cases with the head engaged in the 
cavity or on the floor, treat by forceps. In those cases 
of occipitoposterior positions with the membranes un- 
ruptured he believed in giving Nature a trial and not 
interfering. In a case with membranes ruptured, with 
the head at the brim, if the head was engaged in the 
pelvis and could be rotated to the front with rotation of 
the body, it then was better to deliver by forceps than 
to attempt version, if the operation was to be done by 
one not an expert. He said this because all were not 
experts in the management of the after-coming head and 
in extracting the arms. 

The position taken by Dr. Marx regarding craniotomy 
he said deserved praise and also comment. He had seen 
two cases of rupture of the uterus caused by the applica- 
tion of the forceps when the head was not engaged, while 
at the pelvic brim and in both of these cases the child was 
dead. It was to him surprising how many difficulties 
could be overcome by intelligent craniotomy, and for 
three or four years he had been doing craniotomy when 
the mother's life was endangered. 



Contagious Diseases— Weekly Statement. — Report of 
cases and deaths from contagious diseases reported to 
the Sanitary Bureau, Health Department, New York 
City, for the week ending July 2, 1904: 



Measles 

Diphtheria and croup . . . 

Scarlet fever 

Smallpox 

Varicella 

Tuberculosis 

Typhoid fever . . . 

Cerebrospinal meningitis 



Case*. 



Dcatht. 



.369 


23 


386 


50 


130 


9 


I 


I 


61 


. . . 


330 


'5° 


ii 


12 




39 



A Strange Result of Iodoform Dressing. — H . McNaughton- 
Jones reports this case. The patient, a woman of thirty, 
had recently undergone an abdominal operation. The 
course was favorable until the third day after the opera- 
tion. Irritation and some smarting in the neighborhood 
of the wound was then complained of. The wound had 
been stitched with celloidin-zwirn, a pad of moist steri- 
lized lo-per-cent. iodoform gauze being placed over it 
covered with coeletin. On raising the dressing the nurse 
found some slight swelling and redness along the area of 
the incision. The irritation increased and the next day 
the iodoform was removed and the wound lightly sponged 
over with some weak formalin solution, dried and dusted 
with dermatol, covered with plain sterilized gauze, and 
protected with coclitin. The distress continued and the 
next day several large vesicles appeared. The arms and 
hands now became involved, later the legs. There were 
no constitutional symptoms. The skin healed by first 
intention. It was learned that many years before 
the patient had had 'an ulcer on the leg. This had 
been dressed with iodoform \vith much the same 
results as in the present instance. From her childhood 
the patient had suffered from an eczematous tendency. — 
Midical Press and Circular, February 24, i()04. 

Report of a Case of Perforation in Typhoid Fever in a 
Child of Six Years. — John H. Topson describes this case. 
The child was a male Hebrew child who had been healthy up 
to the time of this present illness. For two weeks he 
had been suffering from malaise, fever, cough, and head- 
ache. Diarrhoea and abdominal v'^i" developed, which 
seemed to be located in the right iliac region. The day 



before his admission to the hospital he began to vomit. 
E.xamination showed his lungs to be clear. The ab- 
dorain was distended and tender, particularly in the 
right iliac region. There were a few suspicious spots. 
Projectile vomiting developed. When seen by the writer, 
the temperature was 98.8° F., pulse 120, respiration 48 
There were noted, abdominal distention, generalized 
rigidity, tenderness, especially in the right iliac region, 
abscence of liver dulness, thoracic type of respiration, and 
abscence of peristaltic sounds. The general condition 
was fair, considering the advanced local symptoms. A 
diagnosis of intestinal perforation during typhoid fever 
was made. Operation showed the perforation to be in 
the ileum, about eight inches from the colon, about the 
diameter of an ordinary lead pencil. The after-history 
was like that of many cases of operation in the presence of 
general peritonitis. Improvement followed for twelve 
hours, but at the end of the first day vomiting and other 
signs of peritonitis occurred, the pulse weakened, and at 
the end of seventy-two hours the patient died. The per- 
foration probably occurred at least twenty-four hours 
before operation. After death the perforation was found 
to be firmly occluded and water-tight. Perforation is 
rarely encountered at such an early age as in this child. 
The writer believes that the case of this patient is possibly 
the youngest yet reported. — Archives of Pediatrics. 

Health Report. — The following cases of smallpox, 
yellow fever, cholera, and plague have been reported 
to the Surgeon-General, U. S. Marine Hospital Service, 
during the week ended July 2, 1904. 



SMALLPOX — UNITED STATES. 



CASES. DEATHS. 



California, San Francisco Tune 12-10 

District of Columbia, Washington .June 11-18 4 

Florida, at larKC June 18-25 7 i 

GeorKia. Macon June 18-25 i 

Illinois. Chicacio June iS-25 i 

Danville June 18-25 i 

Louisiana. New Orleans June 18-25 53 imported 

Mar\land. Baltimore June 18-25 2 

Massachusetts. Lawrence June 18-25 1 

Michigan. Detroit June 18-25 3 

Missouri, St. Louis June 18-25 

Nebraska, Omaha June 18-25 2 

South Omaha June 18-25 •• i imported 

New Flampshire, Manchester June iS-25 

New Jersey. Jersey City June 12-19 



8 



New York, Buffalo June iS-25. 

New York June 18-25. 

Niagara Falls June 18-25. 

Ohio, Toledo June 18-25. 

Pennsylvania. Altoona June 1 8-25 . 

Johnstown June 18-25. 

Philadelphia June r8-2s. 

Pittsburgh June iS-25. 

Tennessee, Memphis June 18-25. 

WashimTton. Tacoma June 13-20 i 

Wisconsin, Milwaukee June 18-25 6 

S.MALLPOX — POREIGM. 

BcUtium. Bnisscls June 4-1 1 

China. Hoiy^komi May 14-28 s 

France, Marseille May 1-31 

Paris June 4-11 10 

Great Britain. Glasgow June 10-17 20 

Leeds June 11-18 3 

London June 4-11 ai 

New-Castlc-on-Tync June 4-1 1 8 

Nottingham June 4-1 1 3 

Sheffield May 28- June 11... 3 

India, Bombay May 24-3 1 

Italy, Palermo June 4-11 i 

lava. Batavia May 7-14 8 

Mexico, Mexico lune s-12 5 

Russia, Moscow May 28- June 4. . . . 11 



. . . . 2, 1 imported 
from Baltimore. 



2 imported, 

1 imported. 

I 3 cases in 

suburban districts. 

7 I 



Odessa June 8-16. 

.M: 



St. Petersburg May 28- June 14. . . 

Warsaw May 21-iS 

Spain, Cadiz May 1-31 

Turkey, Constantinople June s-12 



>S 



16 



3 

23 



YELLOW PBVBR. 



Mexico, Tampico June 1 1-18. 

Vera Cruz June 26. 



imported 



Hawaii. Honolulu. 



fniin Progreso. 

PLAGUE — INSULAR. 

June 21 I 

PLAGUE — FOREIGN. 

China, Amov May 31 Increasing. 

60 

489 

100 

90 

S3 



Hongkong May 14-28. . . . 



596 



Formosa May 14-28. . 

India, Bombay May 14-31 

Calcutta May 21-28 

Karachi May 22-29 

CHOLERA. 

Ohina. Hongkong May 14-28 13 

India. Calcutta -May ^1-28 



Medical Record 

A JFeei'/y Jour/ia/ of Medicine and Surgery 



Vol. 66, No. 3. 
Whole No. 1758. 



New York. July i6, 1904. 



$5.00 Per Annum. 
Single Copies, JOc- 



OMgtnal ArtirlrH. 

PYELITIS COMPLICATING PREGNANCY.*. 

Bv EDWIN B. CRAGIN. M.D.. • 

NEW YORK. 

The occurrence during pregnancy of a marked rise of 
temperature with pain and tenderness on the right 
side of the abdtimen is always a source of anxiety 
to the obstetrician, and its diagnosis and prognosis 
are matters which deeply concern him. 

Although several able articles, by Vinay,' Reed,' 
Brigand.' Haberlin,' and others, have appeared 
describing the condition, it is not generally recog- 
nized by either specialist, or .general practitioner, 
that pyelitis is a not infrequent cause of the above 
■symptoms. 

The condition was first accurately described by 
Reblaud at the surgical congress in 1892. That it is 
not rare in occurrence is evidenced by the fact that 
during the past winter the writer has met with five 
•cases in private consultation work, and including these 
lias seen ten since September, 1900. 

The etiology of the condition seems to depend, 
according to Vinay, upon two factors: (i) Com- 
pression of the ureter by the pregnant uterus. (2) 
Infection of the urinary tract above the point of 
■compression. 

I. Compression of the Ureter by the Pregnant 
Uterus. — Experiments upon animals have shown that 
the urine is excreted under low pressure. Ludwig 
•demonstrated that the pressure in the renal pelvis 
■normally does not exceed 10 mm. of mercury. It 
requires, therefore, but little compression of the 
ureter to retard the current. 

That compression of the ureter with resulting 
■dilatation does occur in pregnancy is proven by the 
records of autopsies on pregnant women by Stad- 
feld, Olshausen. Loehlein, and others. Stadfeld in 
16 autopsies on pregnant wonien, found 9 dilated 
•ureters. In all the writer's cases and in all the 
.authentic cases of pyelitis in pregnancy which he 
could find reported the lesion was primarily right- 
sided and usually confined to the right side. Many 
explanations of this have been given. According 
to Olshavisen,' the right ureter is the one most often 
compressed and dilated in pregnancy. In 16 cases of 
•dilated ureter found by him in autopsies on pregnant 
women, 12 were unilateral, and of these 12, lo were 
right-sided and two were left. As causes of the 
greater compression of the right as compared with 
the left ureter the following have been suggested: 

1. The greater prominence, at the brim of the 
■pelvis, of the right over the left common iliac artery 
•exposes the right ureter to greater pressure between 
the uterus and the iliac artery of that side. 

2. The rotation of the uterus on its long axis from 
left to right, forward, places the uterus and its con- 
tents more in the right oblique diameter of the 
pelvis than in the left, and thus exerts more pressure 
"Upon the right ureter than upon the left. 

3. The greater frequency of the fetal head in the 

♦Read at a meeting of the American Gynecological 
Society in Boston, May 24, 1904. 



right oblique diameter of the pelvis increases the 
frequency of pressure upon the right ureter. 

In support of this view may be mentioned the fact 
that in 8 of the writer's cases the po-sition of the 
fetal head was noted, and in these 8 cases, the head 
occupied the right oblique diameter in 7 ; there 
being 6 in the L. O. A. position, and one in the 
R. O. P. 

Theoretically one would expect, from the greater 
tone of the abdominal and uterine walls, more com- 
pression, and hence more cases of pyelitis, in primi- 
gravidte than in multigravida?, and that was borne 
out in my cases, there being 7 primigravidas and 3 
nudtigravidiE. This is contrary to the experience of 
Vinay, amon,g whose cases there were only 2 
lirimigraviihe and 7 nuiltigr;ivid.e. 

2. Infection of the Urinary Tract above the Point 
of Compression. — From the frequent appearance of 
tln' bacillus typhosus in the urine of typhoid-fever 
patients and from experiments on animals, it would 
seem that in many infective processes the organisms 
may be eliminated by the urine without appreciable 
injury to the urinary tract, provided this tract is in 
no way obstructed. On the other hand, the experi- 
ments of Reblaud and lk)nneau on animals show that 
after an aseptic ligature of the ureter, the injection into 
a distant part of the body of either streptococci or 
colon bacilli can produce a pyonephrosis, it being a 
descending infection. 

Hence with a ureter compressed by the pregnant 
uterus, the infection of it and the renal pelvis is 
favored. The infecting organism in the pyelitis of 
pregnancy is usually the colon bacillus. This was 
the organism found in three of my cases, the only 
ones in which the urine was examined bacteriologi- 
cally, and has been found to be the infecting organism 
in all reported cases examined bacteriologically v/ith 
two exceptions — one by Vinay, in which the strep- 
tococcus was found, and one by Lop which showed 
the gonococcus. 

The period of pregnancy at which the pyelitis is 
most likely to occur is between five and eight 
m<jnths. In all but one of my 10 cases the attack 
appeared at that time. In 3 it occurred at five 
months; in 2 at six months; m 3 at seven montns; 
in one at eight months, and in one at term. 

During the last two years I have also met with 
three cases of pyelitis developing during the puerper- 
ium. These were probably of the same origin as 
those occurring during pregnancy, and recovered 
under the same treatment, but as no bacteriological 
examination of the urine was made, and as ascending 
infection could not be positiveh' excluded, they are 
not included in the present discussion. 

The general course of pyelitis in pregnancy maybe 
seen from the following brief abstracts of cases 
which have come under my observation: 

C.\SE I. — Mrs.F. G.,aged twenty-five, IV gravida. 
Admitted to the Sloane Maternity Hospital, Septem- 
ber 13, 1900. For five weeks previous to admission 
she had suffered with frequent and painful micturi- 
tion, and for the last three weeks with pain in the 
right lumbar region, increased by coughing or other 



82 



MEDICAL RECORD. 



[July 1 6, 1904 



motion. For the week previous to admission there 
had been a rigor each morning, followed by fever, 
sweating, and headache. On the day following ad- 
mission, her temperature was ioi.6° and there was 
tenderness over the right kidney. Her urine was 
acid and contained many pus and epithelial cells. 
She was delivered of a full-term child September 15, 
two days after admission. Position of child L. O. A. 
On the day following delivery the afternoon temper- 
ature was 103.8°. She was given a urinary anti- 
septic, and on the fifth day the temperature came to 
normal and remained so thereafter. The urine 
gradually became clear. Her highest temperature 
while in the hospital was 103.8°. It remained above 
100° for four days. 

C.\SE II. — Mrs. L., aged twenty-three, primi- 
gravida. Admitted to the Sloane Maternity Hospi- 
tal, August 31, 1 90 1. She was in the seventh month 
of pregnancy, anaemic, and complained of pain over 
the right side of her abdomen. Her urine showed 
pus cells and a trace of albumin. Her temperature 
on admission was 102.8'. She was given a urinary 
antiseptic, fluid, diet, and large draughts of water. 
Her temperature and tenderness over the right 
kidney subsided in lour days and the urine gradually 
cleared. Her highest temperature was 102.8". It 
remained above 100° four days. She was normally 
delivered November 11, 1901, and made a good 
convalescence. The position of the child was 
L. O. A. 

Case III. — Mrs. M. G., aged twenty-three, III- 
gravida. Admitted to the Sloane Maternity Hos- 
pital, September 19, 1901, complaining of severe 
pain in the right lumbar region. Her pregnancy 
was seven months advanced, and she stated that she 
had had fever in tie afternoon for several days. 
Her urine was acid and showed pus and epithelial 
cells. There was a trace of albumin^ Her temper- 
ature on admission was 102.8°. She was given a 
urinary antiseptic, milk diet, and large draughts of 
water. Her temperature reached normal on the 
eighth da}' and remained so thereafter, the urine 
gradually clearing. Her highest temperature while 
in the hospital was 104". Her temperature remained 
above 100° for seven days. She was normally 
delivered two months later. Position of child 
L. O. A. Her puerperal temperature did not reach 
99°. 

Case IV. — Mrs. M. H., aged thirty-seven, XIII- 
gravida. Admitted to the Sloane Maternity Hospital, 
April fio, 1903, complaining of sharp pain over the 
right kidney. Her urine was acid and contained 
pus and epithelial cells. Her pregnancy was seven 
months advanced. By May 1 2 the pain had ceased and 
the urine was nearly clear. At no time during her 
stay in the hospital did she show any rise of tem- 
perature above 100°. The position of child was 
R. O. A. 

Case V. — Mrs. D., aged twenty-four, native of 
United States, primigravida. Admitted to the 
Sloane Maternity Hospital, May 18, 1903, stating 
that for two days she had suffered with pain in the 
right lumbar region and fever. On admission her 
temperature was 102.4°. Her urine was acid and 
showed pus and epithelial cells. Her leucocytes 
numbered 22,000. She was delivered of a full-term 
child on the day following admission. Position of 
child R. O. P., rotating to R. O. A. In spite of 
urinary antiseptics, ice-bags to the kidney, fluid 
diet, and large draughts of water, the patient 
gradually grew worse, and on June 3 the right kidney 
was removed by Dr. Joseph A. Blake. The kidney 
showed several small abscesses in its substance, and 
bacteriological examination showed the colon bacillus. 
After a tedious convalescence the patient completely 



recovered. Her highest temperature previous to the 
nephrectomy was 104°. Her temperature prior to 
the nephrectomy was above 100° for sixteen days. 

Case VI. — Mrs. M. G., primigravida, seen in con- 
sultation with Dr. Palmer A. Potter of East Orange, 
N. J., October 14, 1903. Her pregnancy was five 
months advanced. She had had an irregular fever 
for several days with an occasional epistaxis. Her 
temperature when I saw her was 104°. For three 
days prior to my visit she had complained of pain in 
the right lumbar region. The case looked a good 
deal like typhoid fever, and that was my first 
probable diagnosis. The Widal test, however, was 
negative, and subsequent examination of the urine 
showed it to be acid with pus cells, renal epithelium, 
bacteria, and a trace of albumin. She was given a 
urinary antiseptic, fluid diet, and large draughts of 
water. On the third day following the commence- 
ment of the urinary antiseptic, the temperature came 
to normal and remained so thereafter. Her highest 
temperature was 104°. Her temperature remained 
above 100° for nine days. The urine gradually 
cleared. She subsequently went to term and was 
delivered of a living child. Puerperium normal. 

Case VII. — Mrs. G., aged twenty-six, primi- 
gravida, seen in consultation with Dr. George E. 
Steel of New York, December 13, 1903. She was 
six months pregnant, and for forty-eight hours had 
been complaining of pain on the right side of the 
abdomen in the region of the vermiform appendix. 
Her temperature was 102°, pulse 130. The site of 
greatest tenderness was near the McBumey point. 
It looked like a case of appendicitis, and that was 
my probable diagnosis on my first visit. Examina- 
tion of the urine next day, however, showed it to be 
acid and to contain pus cells, hyaline casts, and 
albumin. Previous to the attack of pain, the urine 
had been normal. The diagnosis was changed to 
that of pyelitis, and she was given a urinary antiseptic 
with fluid diet, large draughts of water, and an ice- 
bag over the right kidney. Her pain and tem- 
perature subsided in three days and she made a 
speedy recovery, although the urine showed pus 
cells and casts for more than a month. Her highest 
temperature was 102°, highest pulse, 130; the 
temperature remained above 100° for four days. 
She was delivered at term, March 10, 1904. Position 
L.O.A. Puerperium normal. 

Case VIII. — Mrs. C, aged twenty-seven, primi- 
gravida, seen in consultation with Drs. C. T. Adams 
and F. F. Ward of New York, March 4, 1904. She 
was five months pregnant, and for the month 
previous had complained of pain and tenderness on 
the right side of the abdomen, especially in the region 
of the right kidney, which could be felt enlarged and 
tender. Her temperature during the month prior 
to my visit had been a varied one, ranging from 
normal to 104° with intermissions of several days 
when the temperature was normal. No malarial 
organisms were found and the Widal test was nega- 
tive. Her urine was acid and contained pus cells, a 
trace of albumin, and a few hyaline casts. The 
diagnosis of pyelitis was made and she was given 
a urinary antiseptic, fluid diet, and large draughts of 
water with an ice-bag over the right kidney. Her 
temperature and pain subsided in two weeks after 
beginning the urotropin, but the urine contained 
pus for .1 month longer. Her highest temperature 
was 104°, highest pulse 118. Her temperature was 
above 100° for sixteen days. She is now progressing 
normally in her pregnancy. 

Case IX. — Mrs. P., aged twenty-four, primigra- 
vida, seen in consultation with Dr. D. E. O'Neil of 
New York, April 10, 1904. She was about six 
months pregnant and for three weeks had been 



July 1 6, 1904] 



MEDICAL RECORD. 



83 



complaining of pain on the right side of her abdo- 
men. She had had several slight rigors. Her mic- 
turition had been frequent and painful. On exami- 
nation her right kidney was found enlarged and ten- 
der. Her urine was acid and contained considera- 
ble pus. The filtered specimen showed no albumin. 
Cultures from a catheterized specimen showed the 
colon bacillus. She was given a urinary antisep- 
tic with fluid diet and large draughts of water. Her 
temperature and pain subsided in about ten days 
after beginning the urinary antiseptic. She is now 
progressing normally in her pregnancy, but the urine 
still contains a little pus. The position of the child 
is L. O. A. 

Case X. — Mrs. B., aged twenty-eight, primigrav- 
ida, seen in consultation with Dr. Edwin Stern- 
berger of New York, April 29, 1904. She was about 
five months pregnant, and for two days had been 
complaining of pain on the ride side of the abdomen, 
especially in the appendicular region and in the 
back. This pain at times was intense. Her urine 
was acid, contained a trace of albumin, considerable 
pus, and the bacteriological examination showed 
abundant colon bacilli. Her right kidney could be 
palpated, was enlarged and tender. For several 
days her pain was much worse every other day. 

On May 10 -her leucocytes were 14,400; red cells, 
4,120,000; urea, 296 grains. May 16, leucocytes 
16,000. From April 27 to May 6, in spite of the 
pain in the region of the right kidney and ureter, 
the temperature did not rise above 100.4°. On 
May 7 the temperature reached 101.2", and on 
May 10 104°. For the next three days she be- 
came progressively worse, her temperature on the 
evening of May 13 reaching 105.6", and it seemed 
to me that operative interference would be de- 
manded on the following day. The next morning, 
however, found the patient better, and under the 
advice of Dr. Willy Meyer of New York opera- 
tive interference was postponed. The patient 
steadil)' improved, the temperature reaching normal 
in four days. This case has been characterized by 
more pain than any of the others under the observa- 
tion of the writer. Opiates in some form have been 
frequently required. Her highest temperature was 
105.6°. It remained above 100° for seventeen days. 
The temperature at the time of writing is normal, 
but the pain, although less severe, has not entirely 
disappeared. Aside from opiates for the relief of 
pain, her chief treatment has been with urinary 
antiseptics, fluid diet, and large draughts of water. 
From the above cases the symptom-group can 
fairly well be pictured: 

Pain in the right lumbar region sometimes very 
acute, sometimes only elicited by palpation or 
motion. The pain often follows the course of the 
ureter from kidney to bladder. A rise of tempera- 
ture, usually quite high at some time during the 
attack, 102° to 105°, although in one of my cases 
(Case IV) the temperature did not reach 100°. In 
cases with high temperature rigors are not infre- 
quent. 

Irritability of the bladder with frequent and painful 
micturition is common, but the infection is a descend- 
ing one, and the cystitis, when it does occur, is usually 
secondary to the pyelitis and ureteritis. The right 
kidney can usually be made out enlarged and tender. 
The urine is acid, at first may contain only a trace of 
albumin and perhaps a few casts, to be soon followed 
by pus cells, renal c fntheliiitn , and bacteria. The fil- 
tered urine often shows no albumin. The pus cells 
are usually more abundant as the pain and temper- 
ature subside. The urine often contains pus cells 
for a month or more after the constitutional symp- 
toms have disappeared. 



One of the features of chief interest in pyelitis: 
complicating pregnancy is the diagnosis. In manjr 
cases this is easy if the possibility of the condition' 
is borne in mind. Pain and tenderness in the region: 
of the kidney, a rise of temperature, and an acid 
urine containing pus may point at once to the diag- 
nosis of pyelitis. On the other hand, it must be 
remembered that when an abdomen is occupied by 
a uterus pregnant from five to eight months the pal- 
pation of the other abdominal organs is often diflS- 
cult. Furthermore, there are other conditions 
which may give symptoms resembling it. The 
three conditions most likely to be confused with 
pyelitis in pregnancy are, judging from the writer's 
experience, appendicitis, typhoid fever, and salpin- 
gitis. 

In some of my cases, especially Cases VII and X, 
the point of greatest tenderness has corresponded 
closel}^ -R-ith the McBumey point, and appendicitis 
has been strongly suggested. In each of these cases 
the diagnosis was made from the condition of the 
urine. The reason for the point of tenderness cor- 
responding with the McBurney point seemed to be 
that pressure at this point forced the uterus back 
against the ureter and thus increased the pain. The 
leucocyte count in these cases of pyelitis resembling 
appendicitis has seemed to the writer lower than one 
would expect in an appendicitis case correspond- 
ingly ill-. 

In Case VI the irregular fever and the epistaxis 
resembled typhoid fever, and it was only after the 
negative Widal test, the explanation of the epistaxis 
by the amenorrhoea of pregnancy, and the examina- 
tion of the urine that the correct diagnosis was made. 
The differential diagnosis between pyelitis and sal- 
pingitis can usually be made by the history, the 
bimanual examination, and the careful examination 
of the urine. 

From the above cases it will be seen that the chief 
aid to the diagnosis of pyelitis in pregnancy is. the 
careful examination of the urine; chemical, micro- 
scopical, and bacteriological. 

Although the pain may be very severe and the 
temperature high, even 104" or 105° for a few days, 
the prognosis of pyelitis complicating pregnancy is 
usually good. With the exception of Case V, in 
which the pyelitis started at term and in which the 
substance of the kidney was infected as well as its 
pelvis, all the cases of my series recovered under 
medical treatment, the temperature and pulse sub- 
siding to normal in from four to thirty days; the urin- 
ary changes perhaps persisting for a month more. 
Judging from my own cases and from the reported 
experience of other observers, if the kidneys have 
previously been healthy, pyelitis complicating a 
pregnancy of from five to eight months advance- 
ment, which is the usual period of the complication, 
justifies a favorable prognosis of complete recovery 
under medical treatment. 

In a few cases, however, there are recurrences dur- 
ing the pregnancy, and the possibility' of a pyelitis 
becoming a pyelonephritis, as occurred in case V, 
just referred to, must not be lost sight of. This lat- 
ter possibility seems more likely the nearer the com- 
plication approaches full term and the puer- 
perium. 

The medical treatment which the writer has 
empiloyed in all the cases under his observation is. 
as follows: Rest in bed; fluid diet, especially milk;: 
large draughts of water: urinary antiseptics: ice-bag: 
over the kidney, and, if this fails to relieve the pain, 
an occasional opiate. In many cases, saline cathar- 
sis has given marked relief. If, in spite of this treat- 
ment, there is evidence of extension of the infection 



u 



MEDICAL RECORD. 



Quly 16, 1904 



to the kidney substance, surgical interference by 
nephrotomy or nephrectomy is indicated. 

Interruption of the pregnancy is seldom, if ever, 
necessary or advisable. 

BIBLIOGRAPHY. 

1. L'Obstetrique IV, 1899, pp. 230-256. 

2. Philadelphia Medical Journal, December 9, 1899. 

3. Revue Pratique d'ObsUtrique ct de Pidiatrie, XIV, 
1901. 

4. Miinchener medizinische Wochensckrift, February 2, 
J 904. 

5. "Sammlung klinischer Vortrage, " 39, Gynakologie, 
Nr. 15, 1892. 

10 West Fiftieth Street 



THE TRUE EDUCATION OF MIND AND 
BODY.* 

Bt RICHARD COLE NEWTON. .M.D.. 

MONTCLAIR. N. J. 

To anyone who s-tops to think a moment, it must be 
very plain that there is an incalculable waste of 
power and energy in human life. Man's spiritual, 
mental, and phj'sical powers are capable of almost 
infinite development. It is true that we are 
hampered by many limitations, the span of our life is 
so short, and so much of this brief space must be 
given up to learning what has already been done by 
others in any ])articular field, not to mention the 
entire purview of human knowledge, that there is 
only a short time left for original investigation. 
Furthermore, only a fairly brilliant mind is capable 
of absorbing the existing store of human knowledge 
in any one profession or science, and only com- 
paratively few men and women have the opportunity, 
the industry, and the physical and mental strength 
to become really learned. This, however, is b}' no 
means equivalent to saying that any man during his 
life on earth makes the best practicav use of his time 
and opportunities. 

Most men are engaged in the sordid pursuit of 
money, and spend a great deal of energy and thought 
in endeavoring to circumvent their fellows and ac- 
cumulate money which may never benefit them. 
The struggle for bread is so fierce and our love of ease, 
of sensual enjoyment and social distinction is so 
pronounced, that nine men out of ten think thej' 
have no time for self-improvement, either mental or 
physical. This is far from true. Practically any 
man or woman might be wiser, happier, and healthier 
than he or she now is. There is unfortunately an 
inadequate and one-sided notion of education preva- 
lent in America. Not only do we ordinarily neglect 
the physical side of education, but we are wont to 
look upon a college degree as itself an end, and as the 
distinguishing mark of an educated man. Whereas 
it at best only marks the end of one period of his 
development. The only true and satisfying attitude 
of the mind toward education is that of the his- 
torian, Freeman, who wished it to be said of him 
that he died learning. Neither the mind nor the 
body can safely be allowed to stagnate. If there is no 
progress there will surely be retrogression. 

A non-functionating attribute invariably deterior- 
ates. This is an immutable law of nature, and is 
perhaps in no respect more strikingly manifested 
than in the non-developing minds of those who do not 
study. A man's conduct may improve and his ex- 
perimental knowledge of the world increase with 
years, but unless he actually studies and exercises 
his mental faculties, his intellectual horizon will not 
broaden, nor his mental vigor increase as he grows 
older. On the contrary, his prejudices will take 
deeper root and the bonds of conventionalism will 
bind him more closely. This mental inactivity we 
call conservatism ; but it is really a state of mental 

*Read before the Morristo-n-n Medical Club. 



inertia, in which prejudice, or a blind adherence to 
previously formed opinions, takes the place of 
thought and independent judgment. 

Of course the majority of non-thinkers have never 
exercised their minds enough to have learned to 
think clearly and logically. Stevenson said that he 
"had only to read books to think, but the mass of 
people are only speaking in their sleep." How often 
do we see professional men, teachers and others, 
who have reached an intellectual status after which 
any further progress seems impossible. What is 
more lamentable than a self-satisfied professional 
man, who fancies that he has nothing more to learn? 
Unfortunately he is no exception to the universal 
law, and if there is no advance in his mental con- 
dition, there will be recession. 

A principal, if not the principal, cause of human 
unhappiness is the mental unrest, which is caused by 
the unsatisfied craving for the exercise and develop- 
ment of our God-given intellectual powers. This 
craving is born in aU mankind, it has been called 
the divine unrest, because it leads man ever to 
struggle toward knowledge, toward righteousness, 
and toward freedom. Only the minds that have 
freed themselves by powerful and regular exercise of 
their own functions can shake off the shackles of 
superstition and the bonds of fear. Only minds so 
disciplined can be at rest and await with calmness 
the unfolding of fate, can bear with fortitude the 
struggle with their own limitations, and the in- 
creasing bodily infirmities which tend to occlude 
their vision and thwart their best efforts. Of such 
a mind the good Sir Edward Dyer said three hundred 
years ago: " My mind to me a kingdom is. " Nor is 
the development of the highest type of mind possible 
without a healthy and vigorous body. Nor can this, 
on the other hand, be developed without persistent, 
careful, and properly regulated exercise. In other 
words, leaving out of consideration those human 
anomalies whom we call geniuses, there is no way 
that a man can fit himself to do good work, either 
mental or physical, except by a thorough, painstaking 
development of his mental and bodily powers. 

Unfortunately the average man leads, strictly 
speaking, no intellectual life. He does not really 
think, he docs not read anything that requires mental 
exertion, he does not study. And if we turn our 
thoughts to the gentler sex what do we find? A 
remark of Harriet Martineau's that the poor health 
of American women was due to the vacuity of 
their minds, was unquestionably in a measure true. 
This was made, of course, some years ago, before the 
proliferation of the female college, and the entrance 
of women into the professions, etc. On the other 
hand, an editorial in a leading medical joursal about 
a year ago, in commenting upon the comparative 
sterility of American women, says: "But with her 
growth in brain power, she hasdeclined in physique." 
To this statement the writer takes unqualified ex- 
ception. American women in our day have smaller 
families than their ancestors it is true, but proof is 
entirely lacking that they are of inferior physique, 
and their comparative sterility is due chiefly to an 
improper and unphysiological avoidance of concep- 
tion. This is not to say that there are not numerous 
cases of nervous breakdown amongst women, 
educated and uneducated, from overstudy, over- 
work, etc. However, the percentage of American 
women injured by overstudy must be inconsiderable 
compared to the whole number of women of child- 
bearing age. 

The faulty methods of education now prevalent 
are but too obvious and there is no question about 
the handicaps which bear upon every woman who 
undertakes to develop her mind. Nor can the ex- 



July 1 6, 1904] 



MEDICAL RECORD. 



8c 



periment of giving a woman a. man's education be 
successfully carried out in general, unless girls shall 
be fitted for the contest by a better heredity and a 
more physiological method of life. They must 
develope their muscles and their lungs and live more 
in the open air in childhood, and grow up without 
the impediments of corsets, high-heeled shoes, tight 
clothing and similar abominations, which cramp and 
distort their growing members, itnpair their diges- 
tions and lay the foundation for the nervousness, 
dyspepsia, and the numerous bodily infirmities of 
after years. 

What women suffer from chiefly is want of 
physical development. Had the}' man's muscu'ar 
strength they could easily outstrip him in mental 
acquirements, for at least the first few years of life, 
by reason of their quicker and more elastic minds, 
their greater devotion to their dutes and their 
greater freedom from dissipation and immorality. 
The mistake that our educators have made is to take 
advantage of the girl's willingness to work her 
intense love of approbation and her more rapid 
mental expansion, which is commensurate with her 
rapidly developing body, at the age of puberty, to 
force her along too fast without regard to the con- 
sequences. A woman's bodily health will be as 
surely benefited as a man's by a thorough intel- 
lectual development, but she is more easily injured 
in the process because she is without any question 
the weaker vessel. 

I had begun to hope that the once prevalent notion 
hat a man cannot be learned and physically strong 
at the same time, was becoming passe, and yet in a 
book on health copyrighted last year the following 
appears: "It is an error also to think that great 
muscular development is desirable in a brain worker. 
The two are incompatible.' ' This is one of the hoary 
fallacies which have encumbered medical literature, 
and misdirected medical thought from time im- 
memorial. One would fancy it to have been 
originally the ipse dixit of some lazy and ill-developed 
medical writer, who having no muscle himself and 
being too indolent to acquire any, soon proved to his 
own satisfaction the undesirabilit}^ of having any. 
And subsequent medical writers have slavishly fol- 
lowed this erroneous li.ght, as they have many others. 
There was a kindred notion prevalent a generation 
ago from the tj'ranny of which we have by no means 
entirely escaped, viz., that a man is born into the 
world with a certain fixed amount of energy, which 
he is at liberty to expend in any way he chooses, but 
cannot replenish; so that if our physical side is 
developed, our mental must be dwarfed. Can any- 
thing be more absurd, or more at variance with 
nature's well known laws? And yet, I well remem- 
ber a professor of philosophy, whose name is known 
on two continents teaching that very doctrine to his 
class, of which I was a member, about thirty years 
ago; and there are many prominent teachers, 
preachers and medical men, who believe or affect to 
believe the same fallacy to-day. 

I remember reading in my boyhood in an excellent 
family paper called the Evangelist, this same false 
doctrine, which made a deep impression on my 
youthful mind and gave me serious doubts as to 
whether it was right for me to work in the garden in 
conformity with my father's commands, because it 
seemed a serious thing to impair my chances of 
acquiring an education, merely for the sake of 
raising a few vegetables. And it also filled me with 
consternation to reflect that this vigor or energy, which 
it was assumed that we must carefully conserve for 
the development of our brains, might be so easily 
dissipated, and could not be expended at the same 
time on both bodily and mental exercise any more 
than one can both eat his cake and keep it. 



That the Evangelist meant well in general on 
matters of hygiene was evidenced by the sentiments 
expressed in an editorial article upon washing the 
feet, which also deeply impressed my boyish mind, 
and I may say had a decidedly favorable influence 
upon my habits. As I remember it now, the grava- 
men of the article was that the feet should be washed 
several times a week, instead of once; and the state- 
ment was made that the skin of the feet has great 
powers of absorption, and that the oflFensive matter 
which is excreted through its pores would be re- 
absorbed into the system were it not washed off. 

This, so far as it goes, is true, and the advice is 
sound and may be applicable to-day to at least some 
of the readers of the Evangelist. 

Even in those dark ages of sanitary science there 
were glimmerings of the greatly aroused interest 
which we at present note on this important subject. 
And the fact that an influential religious paper and 
the organ of a branch of the Presbyterian Church, 
did not esteem an editorial upon washing the feet 
beneath its dignity nor out of place in its editorial 
columns, was an evidence of good sense, and re- 
flected credit upon the editor. It showed further 
that the readers of that paper, like the readers of 
current literature to-day, wanted more light, per- 
haps I should say needed more instruction, upon the 
proper methods of living. 

No one in our time who reads the newspapers or 
who attempts to keep abreast with the tendencies 
of modem American life, can fail to notice the ever- 
widening interest displayed not alone in athletic 
sports, but in all matters in any way pertaining to 
bodily health and development. This is the day of 
the ph3^sical culturist in all his forms and with all 
his or her different theories, appliances, and maneu- 
vres, by which vigor is to be attained, lost :nanhood 
restored, dyspepsia banished, and the doctor avoided. 
One "professor" offers for the insignificant sum of a 
dollar to sell to anyone a book containing directions 
which, if followed out, will save the purchaser from 
the necessity of ever paying another doctor's bill. 
There are all sorts of health foods and drinks ad- 
vertised; all sorts of systems of diet, exercise, and 
bathing are promulgated. One man teaches that all 
food of whatever kind should be eaten uncooked. 
Another denotmces the eating of any form of meat, 
while a third instrvicts us that the consiimption of 
nuts will give the most strength, which reminds one 
of the butcher boy in David Copperfield, whose 
preternatural strength was attributed to the beef 
suet with which he annointed his hair. 

This is the day of the man who advocates chewing 
each morsel of food thirty-two times, once for each 
tooth, said to have been a maxim of Mr, Gladstone's. 
Of the man who goes without breakfast ; of him who 
lives on eleven cents a day; of him who eats no salt, 
and of him who cooks all the fruit he eats; of him 
who never takes liquid with his meals, and of him 
who advocates only one dish for dinner. We are 
told to sit or lie naked in the sun, to wear only wool 
next the skin; or linen, or silk, or cotton, according 
to the predilection or self-interest of the adviser. 

The disciples of an alleged school of hygiene in our 
own State lie naked in the earth for several hours a 
day. Some one in Chicago is just now preaching 
against all forms of bathing, while other people 
advise baths for the cure and prevention of every 
form of disease. I have heard doctors in good prac- 
tice advise wearing high-heeled shoes to "maintain 
the integrity of the arch of the foot," while large num- 
bers of people claim to have received benefit from 
the Kneipp cure, a part of the regimen of which is 
to walk barefooted in the dewy grass. 

Perhaps the most revolutionary statement which 



86 



MEDICAL RECORD. 



[July 1 6, 1904 



I have met with lately is that of a "professor" who 
guarantees to increase the stature of any one paying 
him $10, and using his method, from two to five 
inches. This seems to controvert the scriptural 
statement that one cannot add to his stature by tak- 
ing thought, but the world moves and our modern 
"professors" are wonderful fellows. 

One teacher advises against diaphragmatic breath- 
ing; while others hold that it is the only physiologi- 
cal method of respiration. Some would have us 
exercise entirely without apparatus or implements; 
others tell us that only by using the mechanical 
devices in which they are interested can we make 
true progress. 

In Missouri, a State which will ever be famous 
as the home of Osteopathy, a sect of dirt-eaters 
has been started, and we are told that two 
hundred and fifty students in the State Univer- 
sity there have pledged themselves to eat only 
twice daily for the next four months. A college 
trainer last fall forbade the members of the foot- 
ball team to wash in fresh water, forcing them to 
perform all their ablutions in salt water; and so it 
goes; I might, by a little research, indefinitely prolong 
this somewhat grotesque list of more or less peculiar 
performances, which are at present vaunted as con- 
ducive, if not absolutely essential, to health and long 
life. The above list, while incomplete and fragmen- 
tary, serves to illustrate the point which I wish to 
make, viz., that there is to-day a great and con- 
stantly spreading interest in all matters relating to 
the education and care of the body. Our colleges 
spent last year in sports over $1,000,000. At Har- 
vard $250,000 is to be spent for a stadium, from the 
seats of which athletic games shall be witnessed by 
about 40,000 people, while the president of the uni- 
versity makes his annual plea in vain for a suitable 
building in which to house adequately and make 
available the books now in the college library. In 
spite of the protests of a large part of the medical 
profession, of the so-called leaders of thought, 
and of many clergymen, professors, and thinkers, 
the tove of athletic sports increases day by day. 
How many learned opinions have I read in various 
publications, lay and medical, about the evil effects 
immediate and remote which must follow muscular 
development, as surely, if not as speedily, as night 
follows day. 

Sir Benjamin Ward Richardson, an English medi- 
cal writer of some note, said a few years ago that 
he did not believe that there was living in England 
at that time a professional or celebrated amateur 
athlete over fifty years of age who did not pre- 
sent symptoms of heart disease. Many of us can 
remember a novel by Wilkie Collins called "Man 
and Wife," written in great measure at least to decry 
the then increasing love of athletic sports in Great 
Britain. The late Senator Evarts is said to have 
attributed his long continued good health to the fact 
that he never took exercise. There used also to be 
a great deal said about the brutalizing tendencies of 
athletic sports. I remember my own father, after 
giving a reluctant consent to my rowing in a crew 
when in college, adding the admonition that I should 
not, if I rowed, allow myself to become a rowdy. 
Rowing men are not rowdies and athletic training 
teaches self-command and moderation rather than 
otherwise. How well I remember the words of a cel- 
ebrated Boston surgeon of a generation ago, who told 
his son that rowing in races would surely lead to 
heart disease. This young man took little or no 
exercise in college, while his chum was in the uni- 
versity crew. Shortly after graduation from college, 
the former pricked his finger in the dissecting room 
and died of blood poisoning in a few days ; whereas the 



rowing man is now alive and in good health, and has 
practised medicine for nearly thirty years. I might 
add that the brother of the first mentioned 3-oung 
man was a foot-ball player in college, and is now 
alive and well. 

There have been unfortunately too few observa- 
tions upon the subsequent careers of university crew 
men, and it has been easy for medical writers, in dis- 
cussing the subject, of the effect of exercise on the 
heart, to fall into that spirit said bj- Huxley to be 
engendered by the habit of speaking without the 
expectation of a reply. 

Of course there are writers and speakers of con- 
siderable power and acumen who take the attitude 
that if the facts do not fit their theories, it is so much 
the worse for the facts. And there is also a habit of 
the medical mind to forbid all practices of the safety 
of which there can be a reasonable doubt, so that it 
is easier to say do not do that, it may hurt you in 
after years if not immediately, than to say candidly 
I do not know what the effect of severe exercise will 
be upon the heart. Fortunately a number of accu- 
rate observations have recently been made upon 
rowing men during training, and immediately after 
the races, and now G. L. Meylan reports the results 
of an investigation of the subsequent health of one 
hundred and fifty-two Harvard oarsmen who rowed 
in boat races from 1852-1892. He chose oarsmen 
for investigation, inasmuch as there can be no ques- 
tion of the severity of the exercise and its liability to . 
produce immediate or remote effects upon the heart, 
if any exercise can. His observations coincided with 
those of Dr. Morgan, published in England in 1873. 
This gentleman followed up two hundred and ninety- 
four Oxford and Cambridge oarsmen who rowed in 
University races in the forty years from 1829-69. 
All this testimony shows that severe training and 
rowing four-mile races does not produce heart dis- 
ease, nor any other form of disease, and that oars- 
men live longer and are happier, healthier, and the 
fathers of larger families than other educated men 
generally. And Meylan's investigation shows that a 
larger percentage of these oarsmen have attained 
distinction in letters and in the learned professions 
than college graduates who did not row. 

It shows that of the college graduates whose 
names appear in "Who's Who in America," of the 
average graduate the percentage is 2.1; of the Phi 
Beta Kappa men it is 5.9, and of the oarsmen it is 
8.3. 

It is now up to these gentlemen who have said 
such sweeping things about the injury which severe 
exercise in general, and rowing in particular, may in- 
flict upon the health, to produce some trustworthy 
evidence in refutation of Dr. Morgan and Mr. 
Meylan, or to confess, what the writer has all the 
time suspected, that they were going to their 
imagination for their facts, or relying upon hearsay 
and unverified evidence in support of their precon- 
ceived notions. 

The observations of Dr. Morgan and Mr. Meylan 
must be very comforting to many anxious parents, 
who cannot keep their sons out of the college crews, 
as well as to numerous writers and thinkers, who 
have the welfare of their race at heart. For truly 
one might as well try to make water run up hill as 
to try to stem the present rage for athletics. 

A brilliant writer said to me the other day, that 
the world seems to be reverting to the old Grecian 
loveTof physical prowess and admiration for the 
body beautiful. Of course, we arc a long way from 
this yet. Fancy our hollow-chested, pigeon-toed 
women with their square hips and hour-glass waists 
dressed as the Greeks used to dress. Fancy our 
average business man with his protuberant paunch 



July 1 6, 1904] 



MEDICAL RECORD. 



87 



and skinny arms posing as a Greek hero. Sad as 
this thought is, there is room for encouragement. 
Our people, both men and women, are improving in 
size, figure and carriage, and will continue to im- 
prove. Whether the general intelligence and mental 
development will ever reach as high an average 
among us as it did among the Athenians, is quite 
another question. 

The great truth cannot much longer be kept from 
the man of average intelligence and education, that 
the condition of the general health is all important, 
and the special diseased conditions are the exception 
and are frequently the result of preventable causes; 
and that in the majority of cases, when a man is 
sick, the doctor can do him no good except with 
advice, and that he must rely upon his own con- 
stitution and his general health to pull him through, 
if he is to get through. 

The desire for strength, for bodily vigor and come- 
liness, is perfectl}' natural and is born in all men and 
women. As I have just said, it is impossible even 
were it desirable, to stop the present interest in all 
things athletic. On the other hand, now is the 
opportunity for the real lover of mankind to confer 
inestimable benefits upon the race by guiding and 
directing them in the way that thej^ must walk, if 
they would attain real physical excellence. 

First, and most important of all, is to instil into the 
receptive mind of the child the physical conscience. 
He must be taught that it is just as wicked to injure 
his health or to deprive his body of its needed rest, 
recreation and exercise, as it is to steal, or lie to 
commit any sin. The sins against chastity, so dis- 
gustingly and alarmingly common, are also sins 
against the body, not only because of the immense 
risk of contracting venereal disease, but chiefly be- 
cause no high-minded man, who truly respected his 
body, would be guilty of such baseness. 

The medical profession must take stronger ground 
and be more outspoken against fornication, against 
alcoholic drinks, against tobacco, against confec- 
tionery, against gluttony, sloth and weak self-in- 
dulgence — in fact, against all the physiological sins 
which are daily and hourly committed in every part 
of this broad land — in the palace of the rich, in the 
hovel of the poor. But our duty is not done when 
we have forbidden all these injurious things, we 
must enjoin the physical exercises and the rules of 
correct living, without which, the body cannot be 
built up. 

It is a great misfortune that the injunctions in the 
Scriptures to keep our bodies in subjection and 
mortify the lusts of the flesh, etc., should have been 
interpreted to refer to all bodily pleasure, and 
practically to all physical exercise and recreation. 
I submit that we are commanded to restrain our 
appetites, to curb our lust and contend with that 
craving for stimulants and narcotics which is bom 
in every man, but it is inconceivable that we are not 
enjoined to educate and develop our physical powers 
pari passu with our minds, and our morals, if we wish 
to accomplish the moiety of the work in this world 
of whieh the properly developed man is capable. 

There is absolutely no attribute or power of the 
human being, mental or physical, which does not 
need development and exercise and prolonged use 
before it can come anywhere near perfection. As 
M. Georges Demeny says, "The essential of physical 
education is voluntary motion." Massage, rubbing, 
etc.. are at best only substitutes for voluntary exer- 
cise of the muscles. President Faunce of Brown 
University has said, in speaking of the "advantages 
of disadvantage," that college boys take up athletics 
to compensate themselves for not having been 
brought up to work on a farm. In other words, not 



having previously enjoyed an opportunity to acquire 
the phj-sical basis necessary for years of mental 
work and nervous strain; they take to athletic 
sports in college with great avidity, and according 
to the learned gentleman just quoted, in a measure 
make up for their bodily deficiencies in this way. 

You may tell me that certain men have achieved 
greatness in spite of feeble and ill-developed bodies. 
While this may be true in some cases, it is not 
generally so. So far as known, the world's leaders 
have, generally speaking, been of powerful physique, 
and have also been men of simple tastes and ab- 
stemious lives. 

It has even been asserted that no man in this 
country has risen to eminence in either the medical 
or legal profession who has not at some time in his 
life worked with his hands. I may be met by the 
objection that strong and muscular men need much 
physical exercise to keep their robust frames in good 
condition, and that professional men cannot spare 
the time for this. This objection is more apparent 
than real, because all men whether muscular or not, 
need some exercise to keep them well, and fifteen 
minutes hard exercise in the morning beside the cold 
bath, that every gentleman is supposed to take, is 
enough to keep a stalwart body in good health. 
Always provided, that the diet is strictly limited 
and the man leads a correct life in other respects. 

Whatever view of the spiritual life of man one 
may take, a moment's reflection will show that 
healthy and vigorous thinking cannot go on in a 
diseased brain, nor in an improperly nourished brain, 
nor in the brain of an overfed man. Every one 
knows that if he eats too heartily he cannot think 
clearly for some hours afterward, and he also knows, 
if he has watched men at all, that inordinate feeders, 
not to mention drinkers, are of apathetic minds and 
slothful bodies. Whether the brain is a dwelling 
place for the soul, or whether it is a secreting organ, 
and "secretes thought as the liver secretes bile," 
there can be no question that it must be healthy and 
well-developed, and a part of a healthy and well- 
developed body, in order to do its best work. 

All life, as it manifests itself to our senses, is char- 
acterized by action, growth, recession, and decay. 
There is never-ceasing change so long as life lasts. 
It is also evident that under varying conditions, 
plants and animals develop in ever-varying ways, 
so man grows, reaches maturity, decays mentally 
and physically, and dies. Is it reasonable to assume 
that his complex and wonderfully formed body can 
grow up and develop itself properly without thought 
or care, on its owner's part? 

No one disputes with a cattle-raiser or a horse- 
breeder, or even a chicken raiser, about the advan- 
tage, in fact the necessity, for applying the best and 
most recent scientific knowledge to the development 
and care of his charges. Even chicken fanciers make 
their poultry exercise during the winter bj' hanging 
their food nearly out of their reach, so that the 
chickens must jump for it; or burying it under leaves 
or straw, so that they must scratch for it. And 
shall we not make a more thorough study of the 
health and well-being of the human animal? Her- 
bert Spencer says, "The raising of first-rate bullocks 
is an occupation, on which men of education willingly 
spend much time, inquirj', and thought; the bringing 
up of fine human beings is an occupation tacitly 
voted unworthy of their attention." However, his- 
tory repeats itself, while the leaders of thought have 
disdained to busy themselves with the proper nur- 
ture and development of the human body, the nat- 
ural instinctive love of strength and bodily vigor 
which is bom in every Anglo-Saxon breast has reas- 
serted itself, and, as I said before, the interest in 



88 



MEDICAL RECORD. 



[Jiily 1 6, 1904 



everything pertaining to bodily development grows 
apace. And has grown and spread mightily during 
the recollection of men yet young. 

I should not like to leave this subject without a 
few more words upon the mental aspect of education 
in its relation to the physical. I say without hesi- 
tation that the body cannot and will not reach the 
highest state of physical health unless its mental 
powers be also developed. 

This paper is a plea for a symmetrical bodily and 
mental development. Many men will acknowledge 
that for the best mental health a strong and vigor- 
ous body is needed, but I doubt whether it is gen- 
erally appreciated that for the best physical health 
a clear and well-educated mind is essential. In 
fact, we speak of mental and physical health as 
though they were two distinct states, capable of 
existing separately. Nothing can be more errone- 
ous. Health is the normal condition of bodily and 
mental vigor, which every human being should 
possess, and it is as absurd to speak of an 
insane person as being healthy as to say that Stev- 
enson was healthy when dying of consumption, 
although his magnificent intellect was apparently 
still undimmed. 

We have Sandow's authority for the statement 
that one cannot develop a muscle or set of muscles 
without concentrating his mind upon those muscles. 
He saj'S that " It (physical development) is the mind. 
All a matter of the mind, the muscles really have a 
secondary place;" and again . . . "A man 
with strong concentration of mind will develop 
quicker in the quality of his muscles, than will he 
who cannot concentrate his mind upon the matter." 

And these statements I believe to be true. I 
believe also that the bodily and mental powers 
are so interdependent and so indissolubly joined, 
that neither can be exclusively developed without 
injury to both. The body is not only a highly com- 
plex machine, it is a growing, developing, ceaselessly 
changing, living entity. If a locomotive is so con- 
structed that the boiler will generate more steam 
than the steam box can hold, there will be an explo- 
sion as soon as there is a strain put upon the machine; 
and if the boiler, the cylinders, and the steam boxes 
are remarkably strong, while other parts of the 
machinery are weak, there will soon be a breakdown 
and the engine will spend most of its time in the 
repair shop. 

In this last condition is the highly educated man 
who has neglected his body. He has brains, but not 
brawn, and while he is capable of much good work, 
he cannot endure prolonged effort, nor the constant 
hammering which is necessary to achieve anything 
really worth while, half so well as he might have 
done had he more bodily vigor. But suppose in our 
locomotive that the running gear is all right and 
every part of the machinery of the first class, except 
the boiler, no pressure of steam can be generated, and 
the fine and complex machine is comparatively use- 
less. In this state is the man with the great mus- 
cular development, who lacks in mental force and 
application. The stupid and brutal prize fighter, 
without any book knowledge, is as much of a lusus 
natural, a mistake and the result of one-sided train- 
ing as the college honor man who breaks down about 
the time he takes his degree, or shortly afterward ; 
or the neurasthenic college woman, who divides her 
time between reading Ibsen and languishing on a 
couch. Perhaps there is no more striking illustra- 
tion of the want of mental balance which comes in 
many cases, at least from a want of bodily develop- 
ment, than the hysterics of the popular preacher. 
How much more real good would these men accom- 
plish, if their fervor were tempered with moderation, 
and their zeal with that sane and rational frame of 



mind, that patience, courage, and self command which 
hard and long trials of strength and skill engender, 
and which we especially note in men of deep chests 
and stalwart muscles. Not in men like the "lean 
and hungry Cassius, who could not sleep o' nights." 

We want the all around man who does not disdain 
a good meal and pleasant society, a man who likes, 
in moderation, pleasure and sport; in short, a well- 
balanced man who works hard, plays hard, lives 
moderately, sleeps soundly, and is, in short, jortiter 
in re suaviter in niodo. A man who heeds the dic- 
tates of his moral and his physical conscience, who 
lets neither his mind nor his body deteriorate pre- 
maturely by disuse on the one hand, or ill-judged 
over-exertion or weak self-indulgence on the other. 
Who is honest with himself and cultivates a spirit 
of charity toward mankind and reverence toward 
his Maker. Only in such men do we find the cheer- 
fulness and contentment which come from work well 
done. The poise of spirits, the serenity of a well 
acting mind, and the subjugation and regulation of 
the bodily instincts and passions, which are neces- 
sary to a well-ordered manhood and a serene old age. 

How often do we note nowadays in both men and 
women, a condition of mental dyspepsia due to 
improper mental pabulum, to overfeeding the mind 
with fiction and sensational literature; which shows 
itself in the all too prevalent disordered fancies and 
silly theories, which the half-educated call wisdom. 
There is a lamentable lack of a true sense of propor- 
tion in the mental attitude of many teachers and 
writers, partly due, I think, to their ovm ill-devel- 
oped or pampered bodies. 

It is a common saying of the day that educators 
and clergymen are as a class lacking in judgment. 
It is they who support and sympathize with the 
quack and the irregular practitioner. It is they who 
mistake hysteria for piety, effrontery for skill, and 
a flattering tongue for true learning. 

In closing, let me put in one word the great truth 
this paper is meant to inculcate. 

Struggle as we may against it, the conclusion is 
unavoidable that work, steady, regular, persistent 
work, both mental and ph}-sical,is necessary for the 
average man; without it, he will not only not accom- 
plish anything of value, but he will be miserable, 
because while he may not be able to appreciate the 
reason he will be abundantly sensible of the fact that 
he is a failure. 1 

Only the workers have tasted the sweets of living. 
They have been happy because the)^ have 

" Girded their spirits and deepened the streams 
That make glad the fair City of God." 

Our bodies, our mental faculties, our special senses 
are all tools with which the indomitable spirit works. 
These tools may be rough, badly forged, and badly 
tempered, or they may be even, smooth, well forged; 
and exquisitely polished; with which think you wil! 
the best and most enduring work be accomplished! 



Concerning the Practical Value of Recto-Romanoscopy 

— S. Kelen discusses the value of the rectoscope recentl) 
introduced by Strauss, in which the examination of th( 
rectum is simplified by inflating that organ and th< 
sigmoid flexiue with air. The method is particularlj 
effective in ascertaining the condition of the rectum a 
higher levels than those brought into view by the ordinan 
instruments, and the author claims that it is possible t( 
make a diagnosis of lesions in the ampullfe or the beginnin; 
of the sigmoid flexure. He has also been convinced tha 
the rectal tube introduced for the purpose of giving a hig'. 
enema does not pass beyond the ampullee, and suggest 
that the tube be introduced through this instrument afte 
the latter has been inserted about 25 c.c. and the lam 
removed. In this way the liquid is certain to get into tb 
sigmoid flexure. — Pester medizinisch-chirurgisdie Presse 



July 1 6, 1904] 



MEDICAL RECORD. 



89 



A STUDY OF INTESTINAL PERFORATION 
AND PERITONITIS IN TYPHOID FEVER. 
WITH A REPORT OF THREE SUCCESSFUL 
OPERATIONS, AND A STATISTICAL INVES- 
TIGATION OF 295 OPERATIVE CASES.* 

By WILLIAM D. HAGGARD, M.D.. 

NASHVILLE. TENN. 

PROFESSOR OP GYNECOLOGY, MEDICAL DEPARTMENT. UNIVERSITY OP TEN- 
NESSEE, FORMERLY PROFESSOR OF GYNECOLOGY AND ABDOMINAL 
SURGERY. UNIVERSITY OP THE SOUTH; GYNECOLOGIST TO THE NASH- 
VILLE HOSPITAL; FELLOW OP THE SOUTHERN SURGICAL AND GYNECO- 
LOGICAL ASSOCIATION; MEMBER OF THE WOMAN'S HOSPITAL SOCIETY 
OF NEW YORK, ETC. 

The immortal phrase" The resources of surgery are 
rarely successful when practised on the dying" has 
been most wonderfully negatived in the operative 
treatment of perforative peritonitis in typhoid fever. 
Surgery has reclaimed many otherwise irremediable 
conditions. It was a great step when Sims siiggested 
abdominal section for intestinal perforation for gun- 
shot wounds, which daily rescues many victims. It 
was a great step when Fitz and McBurney taught 
us the frequency and means of relief of perforation 
of the appendix, which has saved so many valuable 
lives. But it is a still greater achievement to be able 
to succor the hopeless sufferer from the onslaught 
of a fatal peritonitis from perforation in typhoid 
fever. 

The possibilities of this latter achievement, how- 
ever, have not yet been appreciated keenly enough 
by the profession. It is almost a score of years 
since Mikulicz did his first operation in 1884. Since 
that time, I am only able to collect, from all sources, 
by the most diligent search through the literature, 
together with cases personally communicated, 295 
cases that have been subjected to operation up to 
May I, 1903. Granting that there have been as 
many, or twice as many, cases that have not been 
reported or found, I still claim that the total sum is 
pitiably meagre. For we have only to reflect that 
an estimate of 500,000 cases a year occur in this 
country alone, and with a general death rate of 10 
per cent, to 15 per cent., 50,000 or 75,000 souls perish 
annually from this terrible scourge which we daily 
implore families and municipalities to prevent. 

Osier says that one-third of the deaths from 
typhoid fever are due to intestinal perforation. 
Taylor thus estimates that 25,000 deaths occur 
yearly from this accident. On the basis of a possi- 
ble 30 per cent, recovery by operative interference, 
he further concludes that 7,500 persons perish in the 
United States each year who might be saved. 

The reasons for this are complex. They are partly 
preventable, and partly irremediable at this time. 
One explanation is the reluctance with which the 
practitioner invokes the aid of surgery in the pres- 
ence of such forbidding general symptoms. Another 
is the likelihood of death even with the operation; 
but the greatest of all is the great difficulty of mak- 
ing a positive diagnosis in the early stages. This 
difficulty will always exist with our present methods 
of diagnosis. It inaj^ be considerably lessened by a 
proper appreciation of even the suspicious abdomi- 
nal symptoms, intelligent alertness, and frequent 
examination. 

Perhaps the greatest stumbling-block is the clas- 
sical picture of perforation which needs erasing: the 
drawn, pinched features, pointed nose, profuse 
sweat, cold extremities, rapid, feeble pulse, short, 
sighing respiration, distended and motionlesss abdo- 
men, restlessness and delirium — these are the late 
and lethal manifestations of peritonitis, and not of 
perforation. 

I regret that we have not as characteristic a pic- 

*Read before the American Association of Obstetricians 
and Gynecologists, Chicago. 



ture of the early symptoms of perforation. Some 
cases are fairly typical, but others presenting such 
presumably typical symptoms are found not to have 
perforation. Again, peritonitis may be the first 
symptom. Given a man in the third week of a mild 
attack, without abdominal symptoms and pursuing 
a regular course, who is suddenly seized with an 
acute, paroxysmal pain in the right lower quadrant 
of the abdomen, that causes him to cry out, that is 
unrelieved by ordinary measures, followed by col- 
lapse, subnormal temperature and rapid pulse, which 
are succeeded by a rise in temperattire in a few hours, 
associated with continued pain, considerable tender- 
ness and right-sided rigidity, together with a rapidly 
increasing leucocytosis, the diagnosis of intestinal 
perforation is reasonably certain — not absolutely — 
but surgically. All such cases should be operated 
on as quickly as possible. 

The difficulty is that all cases do not present this 
typical grouping. 

No abdominal symptoms.'objective or subjective, 
occurring in typhoid fever, should be considered 
trivial. Pain is usually the first note of alarm. 

My study of the reported cases develops that c* 
sudden severe colicky pain is present in a large 
majority of cases. Collapse is an infrequent at- 
tendant of perforation, and was present in only about 
6 or 7 per cent. Fall in temperature was not con- 
stant, but rise in pulse was rather uniform. Of the 
physical signs, tenderness (sensitiveness) was found 
to be the most constant. And studied in the order of 
their development, and more especially their signi- 
ficance, it was found that pain, then tenderness, then 
rigidity, and then localization in one spot occurred. 

Persistence of symptoms serves to distinguish 
them from colic which should disappear in a few 
hours or change its location. 

Recognizing the difficulties and limitations in 
diagnosis, exploratory incision should be regarded as 
a necessary and final aid in diagnosis. 

The facts about intestinal perforation, which I 
have deduced from a statistical study of the cases, 
may be summarized as follows: 

1. It occurs more often in men than women — 
80. 9 vs. 19. 1 per cent. It is, like hemorrhage, rare in 
children. 

2. It occurs in about 2.5 per cent, of all cases of 
typhoid fever. 

3. 3.31 per cent, occur in the first week; 20.19 Per 
cent, in second week; 38.94 per cent, in third week; 
14.90 per cent, in fourth week; 9.13 per cent, in 
fifth week; 5.75 per cent, in sixth week; 7.21 per 
cent, from seventh to eleventh week, and has been 
observed as late as the one hundredth day (Cursch- 
mann). Holmes operated on one case after four 
months. 

4. It naturally occurs more frequently in severe 
attacks, but may occur in mild attacks, and it may 
be the first real symptom of so-called walkingtyphoid. 

5. It occurs in the ileum in 95.5 per cent., usually 
in 18 inches of csecum (Osier), always in 3 feet 
(Loison). In the large intestine in 12.9 per cent., 
and is most often situated in the ascending, trans- 
verse, and descending colon, sigmoid and rectum, in 
the order named. It may occur, also, in the ap- 
pendix, Meckel's diverticulum, and jejunum. 

6. The perforation is single in 84 per cent. There 
may be two or more, and in one case there were 
twenty-five (postmortem). Cases with diarrhoea 
and tympany are more likely to have perforation. 
Six out of thirty cases occurred with hemorrhage. 
(Osier.) 

7. The death rate given by Murchison is 90 per 
cent, to 95 per cent. Osier says he could not recall a 



9° 



MEDICAL RECORD. 



[July i6, 1904 



single case in his experience that had recovered after 
perforation had occurred. 

Occasionally the careful observer and con- 
scientious surgeon, in his earnest effort to interpret 
signs aright, and to operate before general peritonitis 
has rendered the patient hopeless, may open the 
abdomen to find no lesion whatever. This has been 
done by the most expert, and will sometimes happen 
until we devise some absolutely earl 3' sign. Com- 
monly the patients progress and get well, as though 
nothing had been done to them. It has demon- 
strated the fact that these patients will bear the 
surgery necessary to make a positive diagnosis in 
suspected, but doubtful cases. Indeed Finney ad- 
vises exploratory laparotomy under cocaine anaes- 
thesia in suspected cases. To be sure, there is some 
chagrin attaching to a seemingly unnecessary 
operation, but it is much better to do such an opera- 
tion upon a mistaken diagnosis, than to neglect to do 
it upon a case that demands it. 

To avoid this embarrassment Connell has in- 
geniously devised recently a procedure based upon 
the fact that sulphuretted hydrogen will, when 
passed through a solution of acetate of lead, turn it 
black by the formation of sulphide of lead. He 
proposes, as the result of animal experinjentation, to 
introduce an ordinary trocar and cannula into the 
lower part of the abdomen in suspected cases of 
intestinal perforation, to insufflate filtered air, which, 
mixing with the intestinal gas in the peritoneal 
cavity, is allowed to escape through another cannula 
at the upper part of the abdomen, into a solution of 
acetate of lead. If sulphuretted hydrogen be 
present as a result of a perforation, the reaction will 
take place. 

Other experiments were made by injecting sterile 
salt solution, and withdrawing it in from three to 
twelve hours. Where the intestine had been in- 
tentionally punctured or opened, and the salt solu- 
tion allowed to mix with the fecal extravasation, 
when it was withdrawn, ammonia could be detected 
by Nessler's reagent, indol by sodium nitrate and 
sulphuric acid and proteoses by the biuret test. 

-None of these tests were positive in air or fluid 
injected and recovered from the normal peritoneal 
cavity. The method appears to be harmless, but 
lacks additional confirmation as to its uniformity and 
reliability. Meanwhile the diagnosis of perforation 
must rest upon the minutest scrutiny of suspicious 
signs, which, if deemed reasonably certain, should 
demand an exploration; or upon the advent of 
peritonitis, it should be imperative. The mild and 
early symptoms are the important ones. The severe 
sjrmptoms usually mean peritonitis. 

t is surgically immaterial whether a perforation 
exists or not if there is peritonitis. It is more apt 
to be localized if there is no great extravasation. 
Peritonitis in typhoid fever may be due to migration 
of bacteria through the intestinal walls without 
actual perforation, as evidenced by the number of 
cases of peritonitis without perforation. It may 
result from ruptured abscess of the liver, rupture of 
the spleen, or of the gall-bladder or ducts, of the 
mesenteric glands, appendix, and from gangrene of 
the intestine caused by thrombosis. 

The surgeon should stand in close relationship 
with the physician in typhoid fever, as is now the 
quite general custom in appendicitis. Gushing 
advises that he should be consulted at the first indi- 
cation of a localized peritonitis, and should perfora- 
tion and extravasation occur, operation may be 
undertaken without delay. 0.sler advises — "In 
doubtful cases patients should be given the benefit 
of the doubt and operation urged {The Lancet, Feb- 
ruary g, igoi). Keen says "We should operate in 



practically every case of perforation, unless the con- 
dition is such that recovery is evidently hopeless." 
(Journal of the American Medical Association, Janu- 
ary 20, 1900.) Further, "after perforation has 
occurred operation should be done at the earliest 
possible moment, provided that we wait till the 
primary shock, if any be present, has subsided.'' 

Case I. — My first case was in 1898, and reported 
in the Transaction of the Southern Surgical and 
Gynecological Association, 1899. Woman, nineteen 
years of age, married eight months. In the third 
week of severe typhoid fever with delirium, a tender 
swelling developed in the right iliac region, that was 
quite frank and prominent. When I incised it, the 
gas and pus were forcibly ejected from the tension 
in the sac. It was larger than a cocoanut, and 
well walled off. The cavity healed in about three 
weeks. The fever progressed with increasing sever- 
ity and she died fromtoxfemia, three and a half weeks 
after operation in the seventh week of the disease. 
Widal's test positive. No autopsy. This case is 
ver)^ similar to case 122, in Keen's list, reported by 
Munro, which is recorded as a surgical recovery. 

C.\SE II. — July, 1901. Boy, nine years of age 
with mild typhoid fever, with some tenderness and 
slight rigidity in the right iliac region that inclined 
us to diagnosis of appendicitis. On the nineteenth 
day he developed symptoms of localized peritonitis in 
the right iliac region. Incision over the slightly dull 
tumor at my clinic at the University of the South re- 
vealed a fairly well walled-off area, the walls of which 
were almost in apposition, the sides and bottom of 
which presented three perforations; two appeared to 
be in the innerwall, composed of small bowel, and one 
in the outer wall orcolon; no pusbut a slight amount 
of fecal fluid. All of these openings were sutured 
and drainage established. A fecal fistula appeared 
on the third day and persisted. He remained in bed 
with typhoid symptoms and temperature for ten 
weeks, and developed a left suppurating parotid. I 
closed the fistula eighteen months afterward with 
success. 

These two cases were examples of the two types 
of local peritonitis: perforation with'abscess forma- 
tion and perforation with walling-off by adhesive 
peritonitis, the perforation still patent. 

C.\SE III. — Example of free perforation. Male, 
aged thirty-four, in previous good health. He was 
under the care of Dr. Sugg of Beachville, Tenn. On 
October 8, 1903 (the twelfth day of the disease), the 
temperature was 101°, instead of 100° as usual; the 
pulse 92 instead of 72 or 80. An enema was given, 
which acted well. At 11 o'clock the patient was 
seized with sudden, severe colicky, abdominal pain-. 
The pain abated somewhat, and when the doctor 
reached him the temperature was normal and pulse 
72. An enema was ordered and a turpentine stupe 
applied. At this time there was little or no tym- 
panitis, nor had there been in the entire progress of 
the case. At 2 p.m. — three hours after the onset of 
pain — the patient was still suff'ering with considera- 
ble abdominal pain. There was slight tenderness 
over the abdomen, which was most pronounced in 
the right lower quadrant, extending a trifle to the 
left of the median line. There was slight abdominal 
distension. The temperature had risen to 104° and 
pulse was 120. The face was anxious and appre- 
hensive. 

Dr. Sugg made the diagnosis of perforation. The 
patient was ten miles in the country, and I reached 
him seven and one-half hours after the onset of pain. 
The conditions were unchanged, except that the tem- 
perature had receded to 1 o 2 . 6° and the pulse was 116. 
The sudden onset of acute abdominal pain in the 
second week of a mild case of typhoid fever, followed 



July 1 6. 1904] 



MEDICAL RECORD. 



91 



by rapid rise in temperature and pulse-rate, the 
anxious facies, the undiminished pain, the distention, 
tenderness, and rigidity indicative of beginning peri- 
tonitis, pointed quite strongly to perforation. 
Although it was after night-fall, in a three-room 
farm house, with no facilities for operating, yet in the 
face of an otherwise fatal issue, and with the 
patient's consent, preparations were made as rapidly 
and completely as possible, and abdominal section 
was made eight and one-half hours after the onset of 
pain. When the peritoneum was opened in the right 
semilunaris, a quantity of free, odorless, chyme-like, 
yellow fluid made its escape. The caecum was at 
once located and pulled up with the appendix for 
inspection. The latter was found to be normal. 
The adjacent ileum was deeply injected and pre- 
sented a modena-color, and was slimy from being 
bathed in the pea-soup effusion. It was passed 
between the fingers for a few inches, and at about 
twelve inches from the caecal extremity the per- 
foration was found. The actual opening was small 
and situated in the center of an indurated area about 
as large as a five-cent piece. Upon manipulation there 
exuded from the perforation yellowish intestinal 
contents corresponding in color and odorlessness to 
the free fluid found in the cavity. The knuckle of 
gut containing the perforation was surrounded by 
gauze pads, and the indurated area containing it was 
inverted by five Lembert sutures of small silk. A 
second layer was placed above and between the first 
row and at the angles. 

The sutured area was temporarily surrounded with 
gauze and replaced in the cavity pending the 
peritoneal toilet. As much of the pea-soup material 
as possible was sponged out of the right iliac fossa 
and the pelvis, and then the cavity was filled with 
salt solution poured from a pitcher. The small 
quantity that was prepared in the limited time was 
exhausted before the cavity was at all clean, and 
here came the greatest technical difficulty of the 
operation. There was an abundance of boiling 
water, but no cool boiled* water. A by-stander was 
sent to the spring with a clean pitcher for water 
which had to be dipped up, this delayed us some 
minutes. I thought the unsterilized water was less 
harmful than the known septic fluid. The irrigation 
was satisfactorily completed, and the patient turned 
on his side and all fluid allowed to run out. The 
gauze around the injured intestine was replaced by 
two clean gauze strips which met under the perfora- 
tion, and were so disposed as to bring that portion just 
under the incision. A gauze strip was introduced in- 
to the bottom of the pelvis, and another in the right 
flank, and the wound closed by interrupted worm- 
gut sutures. The entire operation comprised th'rty- 
eight minutes, including the delay. 

The pulse at completion was 96, and not above 84 
on the following day. The temperature did not ex- 
ceed 100.8°. On the second night the temperature 
reached 102°, and the pulse, after the excitement of 
being told of his serious condition by his wife, went to 
120. With that exception the pulse did not go above 
108. The facies during the second night was 
anxious, the legs flexed, the respiration difficult, 
nausea was persistent and vomiting frequent and 
offensive. There was considerable distention and 
severe pain, requiring ^ gr. morphine, with marked 
subsidence of the symptoms. Flatus was passed in 
considerable quantity toward morning and the 
patient was more comfortable, but the mind was not 
dear. The gauze was removed in forty hours, being 
loosened by hot salt solution introduced by a glass 
catheter, which was allowed to run into the abdomen 
until it came back clear. The bowels moved well 
after this, and the case progressed satisfactorily with 



a morning remission to ioo° and an evening ex- 
acerbation to 101°, pulse varying from 84 to 96. 

On the twenty-second day of the fever and the 
tenth day after operation the temperature remained 
normal for two days and the stools appeared normal. 
On the twenty-fourth day he had a relapse, the 
temperature reaching 102.6° and the pulse 108. The 
tympany returned, rose-spots again appeared on the 
chest and abdomen, and the stools became loose and 
offensive. Defervescence occurred in the fifth week, 
the temperature returning to normal, and the belly 
became scaphoid. The patient became brighter and 
hungry. He was again considered convalescent, but 
after three days of convalescence he became somno- 
lent and listless; the urine diminished in quantity 
and was found to contain albumin in considerable 
quantity. He was greatly weakened, but was able to 
leave his bed in the eighth week and has remained 
well since. 

Technique. — Inasmuch as the usual site is near the 
ileocsecal valve the right iliac incision should be 
chosen. In cases of general peritonitis a central 
incision is better. The ulcer when found, may be 
trimmed or excised, or simple invertion suture seems 
to be competent. The mattress suture has the 
advantage of only one knot for two threads. The 
second row may be continuous to save time, and a 
third may be added if it does not constrict the lumen 
too much. Sutures may be transverse or longitudi- 
nal. Care should be taken not to cut off too much 
of the circulation when the ulcer is situated near the 
mesentery. 

The Cargile membrane is recommended for addi- 
tional protection. Search should be made for other 
perforations and any thinned areas inverted by 
suture. Resection may be nractised if there is much 
destruction, but the formation of an artificial anus 
is best in the majority of cases in greatly debilitated 
Subjects. Escher saved three out of four cases by 
ileostomy. Copious irrigation is essential in extrav- 
asation or general peritonitis. Sponging out is bet- 
ter in localized and walled-ofif areas. 

Drainage by the vagina is preferable in women. 
Lumbar punctures and drainage by tube and gauze 
is expedient in men. Most of the wound may be 
left open with advantage and the damaged area cof- 
fer-dammed with gauze and located very near the 
incision. To facilitate drainage and localize infec- 
tion in the less vulnerable pelvic peritoneum, instead 
of the fatally absorptive diaphragmatic area. Fowler 
advocates sitting the patient up at an angle of 40 
degrees. Murphy reported six cases — consecutive — 
of general peritonitis (one typhoid) in which recovery 
followed when this was done. I have for some years 
been turning the drained cases of appendicitis on the 
right side from the start with this idea in view. 

Statistics. 

Westcott collected 83 cases in 1897 (published by Keen) 
with 16 recoveries, 19.36 per cent. 

Tinker collected 75 cases in 1898 (published by Keen) 
with 21 recoveries, 26.66 per cent. 

I have collected 137 cases (published and unpublished) 
with 43 recoveries, 31.31 per cent. 

This makes a total of 295 cases, with 80 recoveries, 
27.11 per cent. 

Of this grand total only 246 were sufficienth'' com- 
plete for purpose of study. Of this number there 
were : 

89 cases of free perforation, with 29 recoveries, 36 per 
cent. 

19 cases of localized peritonitis, with 9 recoveries, 47.3 
per cent. 

138 cases of general peritonitis, with 29 recoveries, 21 
per cent. 

There were 16 cases at Johns Hopkins up to 1901, 
with 6 deaths, 37.5 per cent. Cushing had 11 cases 
with 5 recoveries, or 45.5 per cent. He predicts that 



92 



MEDICAL RECORD. 



Quly 1 6, 1904 



the percentage of recovery will soon be from 50 
to 60 per cent. 

I feel that a saving of over 27 per cent, in all cases, 
good'and bad, extending over a period of twenty years 
is a most encouraging showing, and that 36 per cent, 
in cases of free perforation should encourage us to a 
more prompt diagnosis and the invocation of surgi- 
cal relief to these otherwise hopeless subjects. 

A more general appreciation and application of 
the possibilities of operation for typhoid perforation 
will not only be a great surgical triumph, but will 
add many precious years to the span of human life. 



IMPROVEMENTS IN ANESTHETIC APPARA- 
TUS AND TECHNIQUE. 

Bv JAMES T. GWATHMEY M.D.. 

NEW YORK. 

AN/ESTHETIST TO GOUVERNEUR. NEW YORK SKIN AND CANCER, AND 

THE CITY HOSPITALS. 

In a progressive science like that of anaesthetics we 
must constantly expect improvements. A few new 
ideas and methods that have been tried and found 



kept by the anaesthetist. The amounts given in sim- 
ilar cases for the same length of time, and by differ- 
ent methods, would also prove of inestimable value. 

If the case is a diflicvdt one for the anaesthetist, 
the pulse should be taken by the non-sterilized nurse. 
There are many other reasons for an anaesthetic 
chart in both public and private cases, but the above 
are sufficient. 

That Junker's Inhaler is not more often used in 
our hospitals in operations about the head, is due, 
in the writer's opinion, almost entirely to the idea 
of giving chloroform through a closed inhaler and 
mask with valves. Take the margin of a German 
ether inhaler as a model for the face-piece, having 
this perforated with holes around the inner margin, 
and the rest of it made as an ordinary chloroform 
mask. Covering this with two layers of gauze, and 
using a two-ounce bottle with a stopper and catch 
(instead of a screw stopper), we have a very simple 
form of inhaler. If the small mask is fovmd to be in 
the way, the metal tube may be substituted and 
used also as a retractor, the anaesthetizer thus becom- 






ANESTHETIC CHART. 



.7S0_ 



AnnANOco av on cwathmct. 



Bit Dr.. 
Heart _ 
lungM _ 
Unne 



Patients. 
Address _ 

Ag» 

Sex 



WeilU^ 



CotnpUcaiioru . 



-,i 







n 


If 


si 


I-' 




FIRST 


HOUR 










SECOND 


HOUR 














THIRD 


HOUR 




















soo 

140 
ISO 
190 
100 
•0 
80 
TO 
60 












































































































































































































■ 






























































































































H 




















































































3 


































































































































































































































































































































i 
































1 
















i 












1 














1 














s 
5 


Before DiuiBf 

Rnnni ^ Hmira 


After 




















































_ 





___ 




















. Pupa* . 



Vooitiaf - 



Toul time uienbMia «ad opermtloo. Roan 

Prom eompletioa ul opontloa l^ coasciooscet^ Mloutc* ^ 
Aorithctiw I 



. SliBoUot* aeedcd . 



musHio ■« THC KMT-sCHiifwn CO. Ntw Tonhu. s. a. 



of value are herewith oflered lor what they may be 
worth. In order to facilitate the acquirement of 
more exact knowledge by everyone concerned, an 
anaesthetic chart should be in every hospital, regard- 
less of the method or anaesthetic used. 

The surgeon would thereby get more exact data 
on all cases, and the hospital interne be compelled 
to give closer attention to details. In all chloro- 
form anaesthesias the pulse should be taker every 
five minutes, the time recorded at the top of the 
chart and the rate by a dot on its respective line. 
This should also apply to all chloroform mixtures, 
as the A. C. E. (alcohol 1 part, chloroform 2 parts, 
ether 3 parts) or C. E. (same as above with the alco- 
hol left out). During ether narcosis, the pulse-taking 
would depend entirely upon the patient's condition 
and the nature of the operation, but, as a gen- 
eral rule, the pulse should be recorded as above. 
The charts are arranged in book form with a carbon 
sheet, so that one chart may either be placed on file 
(if a hospital case) or given to the surgeon, the other 



ing an assistant to the surgeon, instead of hampering 
him. I have used this inhaler in over fifty very 
difficult cases, most of them over three hours and 
two of them over four hours in duration. Several 
of these cases were athletic alcoholics, such as give 
most trouble to the anesthetist, but it has never 
failed to .give satisfaction. For extirpation of the 
tongue and similar operations where the surgeon 
prefers an analgesic rather than an anasthetic state, 
when a cough or swallowing movement materially 
aids in clearing the throat, this level of narcosis can 
certainly be maintained by this method more easily 
than b}- the drop method. 

The Gwathmey chloroform inhaler then (a modi- 
fication of Junker's) consists of a two-ounce bottle 
with a metal tube running to the bottom, and con- 
nected on the outside with the afferent tube from 
the hand-bellows. The efferent metal tube s'mply 
perforates the rim of the bottle, and is connected 
with the mask by another rubber tube. The bottle 
is graduated to hold 8 drachms, which is usually 



Jtily 1 6, 1904] 



MEDICAL RECORD. 



93 



sufficient, although in the case of alcoholic subjects 
an extra 4 drachms should be added. On pressing 
the bulb, air is passed through the anaesthetic and 
the chloroform vapor carried to the mask by the 
efferent tube. If at the end of six minutes the 
patient is not unconscious, additional chloroform 
should be sprinkled upon the mask. While it is not 
the intent'on to go into details in an article of this 
kind, it may be well to state here that after the 
patient has become quite unconscious, "only small 
doses are required to maintain anaesthesia, as it is 




Fig. I. The Gwathmey oxygen-chlorolorm inhaler. 

necessary to introduce only so much further chloro- 
form as is required to replace what is lost by exhala- 
tion, and thus to maintain in the blood that per- 
centage of chloroform which at first was required to 
induce anassthesia." (Luke.) A metal stop-cock 
has been placed on the efferent tube, and by turning 
this, the percentage of chloroform vapor can be 
easily regulated. 

Whenever possible, the nitrous oxide-ether se- 
quence should be used as a preliminary, the change 
to chloroform being cautiously begun with the 



field). Many surgeons have recommended this 
method whenever chloroform is indicated. If it is 
necessary for the anaesthetist to keep the throat 
clear of blood, etc., during the operation in addition 
to maintaining the level of anaesthesia called for in 
order to have the use of both hands, he simply drops 
the buib on the floor and makes the necessary pres- 
sure with eith-er foot. The meial tube and mask are 




Fig. 3. Combination gas-ether narosis. 

to be Sterilized before and after every operation. If 
any chloroform is left ir the bottle, it should be 
thrown away. 

From experiments recently made by myself with 
this apparatus — using a closed inhaler — and killing 
between 50 and 100 cats. I can state that a mixture 
of oxygen and chloroform is three times as safe as 
one of air and chloroform and almost as safe as ether 




Pig. 2. Bulb on the floor — giving the ansesthetist the use of both hands. 

return of the reflexes, such as a cough or swallowing 
movement. When the above method is used, 
"chloroform anesthesia may be maintained with a 
nsk to life which is so small as to compare very fav- 
orably with, if it does not actually reach, that of 
ether ana;sthesia" (Hewitt). If at any time, the 
patient is troubled with shallow breathing, a few 
drops of ether on the mask will quickly remedy this 
condition. "Overdosage is less apt to occur with a 
Junker's Inhaler than with the drop bottle" (Blum- 




FlG. 4. Combination oxygen-ether narcosis. 

and air. Details regarding the results of these 
experiments will be given in a subsequent article. 

Since the introduction of gas-ether inhalers into 
our hospitals, the criminal carelessness with which 
they are treated deserves attention. Because they 
are on the anaesthetist's table the surgical nurse or 
whoever may have charge of the instruments seems 
to think that it is unnecessary to give any more 
attention to them than to an ether or chloroform 
bottle. Doubtless many cases of pneumonia have 



94 



MEDICAL RECORD. 



[July 1 6, 1904 



already been contracted from these septic inhalers. 
All the metal parts of the inhaler should be boiled, 
and all rubber parts should be treated with a car- 
bolic solution, 1-20, and dried carefully. They 
should not be put together until the anaesthetist is 
ready to use them again. In all operations where 
the anaesthetist may come in contact with the sur- 
geon or his instruments, the inhaler and all instru- 
ments of the anaesthetist should be sterilized, a ster- 
ilized towel should be placed over the anaesthetist's 
table and sterilized gauze wrapped around the chlo- 
roform bottle and ether can. If the above is carried 
out, the anaesthetist may with propriety "wash up" 
and put on white sterilized gloves, but otherwise it 
is nonsense. 

As the valves of the Gwathmey gas-ether inhaler 
are absolutely independent of each other, two com- 
binations are possible with this inhaler, that cannot 
be given with any other. With the ether chamber 
turned on full, and the expiratory valve on the face- 
piece open, keeping the gas-bag connected with the 
gas tank and maintaining a positive pressure in the 
bag, thus allowing the gas to flow through the ether 
chamber, a very satisfactory combination gas and 
ether narcosis can be given. At every third or fifth 
breath remove the mask and allow an intake of 
fresh air. A soft, easy breathing, with a slow pulse, 
is thus secured and maintained. This anaesthetic is 
indicated where for any reason it is desired to abolish 
the reflexes and yet give as little ether as possible. 
By this method a deeper anaesthetic than gas and 
air or gas and oxygen is secured, but not as deep as 
ether alone. The cases must be selected — middle- 
aged women and feeble men can be easily carried 
several hours. Athletes and alcoholics will not take 
it so readily. It requires close attention, for as soon 
as the mask is removed, the patient recovers, and if 
properly given there will be no nausea or vomiting. 
iiRxxx of ether every five minutes is usually suffi- 
cient. 

The combination of oxygen and chloroform 
has been given thousands of times by placing 
a tube from the oxygen tank under any ether 
mask, but this means unknown quantities of 
both oxygen and ether. By allowing the oxygen 
to flow continuously through the ether chamber (as 
in the gas and ether combination) the oxygen carries 
with it the ether fumes. This anesthetic is indi- 
cated in all conditions of shock and collapse. I have 
given this for over one hour and a half to a patient 
with intestinal perforation. The radial pulse could 
not be felt at any time before or during the opera- 
tion, but the pulse continued good, and the general 
condition was better after the operation than before. 
In ordinary cases the pul^e will go as high as 115 or 
120 with the commencement of oxygen, but will 
drop back again to normal in five to ten minutes, 
and so remain. 

For the tri-sequence, one should use^lthe gas- 
sther sequence as a preliminary, and then ether 
in the usual way. If the operation lasts over 
two hours, continue the anaesthetic as in the gas- 
ether combination. In other words, in all long 
operations, the last part should be more of a gas 
than of an ether anaesthesia. By. this method the 
patient is thoroughly conscious at the end of the 
opc-ation, and there is always less nausea and vomit- 
ing. 

Too little attention has been paid to this some- 
times most distressing part of an operation. A 
prominent surgeon said, "The only way to prevent 
this, is to cut the patient's head off." But in over 
90 per cent, of all cases this condition can be pre- 
vented by the observance of the following well- 
known but usually neglected rules: (i) Keep an open- 



air way at all times (not an easy thing) by keeping 
the head to one side and the jaw pressed well for- 
ward. (2) As soon as the anaesthetic is removed, 
replace the ether odor by any other stronger smell, 
salts or cologne (if not too sweet). This is on the 
theory that the olfactory nerve is largely responsible 
for at least the initial symptoms, and results would 
seem to indicate that this is correct. More than 
merely "not to kill the patient" is demanded of the 
anaesthetist of to-day. Close attention to technique 
and nicety in every detail have elevated anaestheti- 
zation to the place it now holds. 
124 East Sixteenth Street. 



HAY -FEVER, SOME PRACTICAL SUGGES- 
TIONS AS TO ITS MANAGEMENT AND 
TREATMENT. 

By RALPH WAIT PARSONS. M.D.. 

OSSINIMG, N. T. 

Of the many diseases to which man is heir, few are 
more intractable, and as regards the results of treat- 
ment, few more unsatisfactorj', than the condition 
commonly known as hay-fever. Particularly is this 
the case when the patient either declines, or is un- 
able to avail himself of the services of a physician 
who is skilled in the treatment of the diseases of the 
nose and throat. 

Some patients with hay-fever do not experience 
much inconvenience from their malady; but, in a 
large number, the discomfort and actual suffering are 
so great as seriously to interfere, at times, with their 
business pursuits and social enjoyment. 

Hay-fever being essentially a chronic affection, 
time and patience are important elements in tht 
treatm.ent of the disease. 

I feel confident that if the hygienic and thera- 
peutic measures herein advocated are adopted, 
many patients suffering from hay-fever will find 
considerable relief from the annoying symptoms of 
the disease, and some will be permanently cured. 
The patients should be urged to carry out the 
physician's directions carefully and systematically, 
in order that the best results of treatment ma}' be 
obtained. 

A few words as to the predisposing causes of the 
disease. It is generally conceded that there are 
three conditions which are necessary for the pro- 
duction of hay-fever, namely: (i) An irritant to the 
nasal mucous membrane, such as pollen, dust, etc.; 
(2) a neurotic habit; (3) an obstructive lesion in the 
nose. 

It is not my intention in this paper to enter into 
the discussion of the pathology or symptomatology 
of hay-fever. These have been so thoroughly de- 
scribed in textbooks on the diseases of the throat 
and nose, and especially in the admirable work of 
Dr. Bosworth, that we need not dwell upon this 
branch of the subject. Suffice it to say that Dr. 
Bosworth lays stress upon the fact that he con- 
siders hay-fever as being due to a vasomotor paresis 
of the walls of the blood-vessels lining the nasal 
cavity, while the asthma which in many cases, sooner 
or later, makes its appearance in the course of the 
disease, is a vasomotor paresis of the blood-vessels 
of the mucous membrane lining the bronchial tubes. 

Treatment. — The treatment of hay-fever may be 
most convenientlj' discussed under three separate 
heads, namely: (i) Constitutional; (2) local; (3) 
treatment of the exacerbation. 

I. Leading authorities on the subject of hay-fever 
are agreed that the disease occurs in the large 
majority of cases in persons of a neurotic tempera- 
ment, and that the treatment adopted should be 
directed toward building up the tone of the nerrous 



July 1 6, 1904] 



MEDICAL RECORD. 



95 



system, with especial reference to the local nervous 
instability, which manifests itself in the nose, as 
above mentioned. 

(a) One of the best agents for securing a good 
tonic effect upon the nervous system is the daily 
morning cold plunge, which is to be taken immediately 
on rising. The immersion need only last for half a 
minute, followed by vigorous rubbing with a coarse 
towel. The use of the bath should be commenced 
several weeks before the itsual time for the hay-fever 
to make its appearance. For those not in robust 
health, cold sponging of the neck and chest should be 
resorted to. 

(6) The mode of life, diet, and exercise should be 
regulated. 

(c) Patients suffering from hay-fever are verj' 
susceptible to taking cold. The}' have a tendency 
to perspire easily, and if they allow themselves to 
cool ofT too suddenly, or expose themselves to a draft, 
they are verj^ apt to bring on a paroxysm of sneezing. 
Hence suitable clothing and shoes should be worn. 

id) The sleeping-room should be well ventilated. 

(c) Ner^-e tonics, such as strychnine, arsenic, and 
phosphorus, are indicated. 

2. In nearly all cases of hay-fever there is a 
pathological condition in the nose, which acts as a 
predisposing cause to the development of the disease. 
This being the case, a thorough examination should 
be made of the nose and nasopharynx of every 
patient suffering from hay-fever. If any chronic 
inflammatory condition be found, it should be 
alleviated ; if any obstructive lesion exist it should be 
removed. All sensitive points should be touched 
with a caustic, such as a solution of nitrate of silver. 

As a rule, hay-fever patients do not come under 
observation until the onset of the exacerbation, 
which, however, is not a favorable time for the 
treatment of the intranasal conditions above men- 
tioned. Whenever possible, patients should be 
urged to place themselves under treatment in the 
spring, or at least, several weeks before the time 
when the symptoms of hay-fever usualh" make their 
appearance. By relieving any hypersemic, or hyper- 
trophic condition, or by removing any nasal ob- 
struction, such as polypi, spurs or deflection of the 
septum, the severity of the onset of the attack may 
be more or less diminished. This plan of treatment 
may need to be renewed at the same period for two 
or three years, before marked improvement in the 
severe cases can be expected. 

3. The theory that the uric-acid diathesis should 
be considered as a factor in the production of hay- 
fever, as taught by such authorities as Haig of 
London, Bishop of Chicago, and Wilson of Elizabeth, 
X. J., should be given due weight in our considera- 
tion of the treatment of the exacerbation. Dr. 
Norton L. Wilson {A'ew York Medical Journal, 
December 26, 1896) makes a strong plea for the 
uric-acid theory in the production of hay-fever. He 
recommends the adoption of active measures for the 
treatment of the uric-acid diathesis six weeks or two 
m.onths before the expected onset of the exacerbation. 
He suggests the administration of aromatic sulphuric 
acid, or phosphoric acid, for a time, followed bj' 
small doses of salicylate of sodium, three grains three 
times a day, and cutting off the acid-producing 
drinks, such as beer, wine, cider, lemonade, etc. 
The following acid-producing foods, especially meat, 
should be avoided: all glandular organs, straw- 
berries, coffee and tea, meat extracts, vinegar, sour 
pickles, preserves, sugar, potatoes, and other starchy 
food. Ham and bacon may sometimes be allowed. 
The diet should consist principally of cereals, eggs, 
fish, fresh fruits, vegetables, milk, and cocoa. Water 
should be drunk freely. Dr. Bishop recommends 



that the patient should take one or two teaspoonsful 
of acid phosphate in a glass of water at bedtime and 
on rising in the morning. 

According to many observers, notably Dr. Beaman 
Douglas, the most satisfactory agent at our disposal, 
for internal treatment of hay-fever, is the saccharated 
extract of the dried suprarenal gland, while the 
active principle of the suprarenal gland is very 
efficient in solution in the form of a spra3^ In the 
proper doses, the extract of the suprarenal gland, 
slows the heart, and increases the force of tBe 
systole. It retards the pulse and stimulates the 
constriction of the blood-vessels. The blood-pressure 
is increased. If a solution of suprarenal extract be 
applied to a mucous surface, the capillaries become 
markedly contracted, and the tissues become more 
or less blanched. Congestion of the nasal mucous 
membrane is diminished and the water\' secretion is 
rendered less copious and less irritating. The same 
is true when the active principle of the gland is used. 

Dr. Douglas, in his paper, "The Treatment of Hay- 
fever by the Suprarenal Gland" {New York Medical 
Journal, May 12, igoo), gives 5 gr. every two 
hours, day and night, until giddiness or palpitation 
is observed, or until the remedj'' seems to be control- 
ling the vasomotor paralysis in the nasal mucous 
membrane. Then the dose may be given at longer 
intervals, say every three hours, and later every six 
hours. The amount may even be diminished to 
two doses of 5 gr. each a day, which are to be con- 
tinued during the hay-fever season. If disagreeable 
symptoms of hay-fever recur, the dosage should be 
recommended as already described. He looks upon 
it as almost a specific in some cases. 

The solution of adrenalin is best used as a spray in 
the proportion of 1-5000 in normal salt solution. 
The strength may be increased if found necessary. 
Prior to its use a spray of some mild alkaline solution 
may be used, and after its use it is well to apply a 
bland oily spray. It must be borne in mind that the 
solution is prone to decompose if exposed to the 
light. It is therefore necessary to keep it in a dark 
bottle, and it is also well to protect the bottle at- 
tached to the atomizer with a piece of dark paper. 

I would advocate beginning the use of the supra- 
renal extract about two weeks before the time the at- 
tack of hay-fever usualty occurs, taking 2 gr. three 
times a day with a view to retarding and mitigating 
the attack, as far as possible. 

The quantity' and irritating quality of the secre- 
tic>n of the nasal mucous membrane is diminished 
bv (i) treatment of the uric-acid diathesis; (2) 
treatment of the intrana-^al pathological conditions; 
(3) the use of the suprarenal gland. 

Xext to the congestion of the nasal mucous mem- 
brane, the most important symptom which presents 
itself is bronchial asthma. According to Bosworth, 
bronchial asthma occurs, sooner or later, in a large 
number of cases of haj'-fever. In his opinion, the 
asthma accompanying hay-fever is due to the prin- 
cipal predisposing cause of the disease, namely, a 
pathological condition in the nose. By directing out- 
treatm.ent to these local causes of irritation the 
hav-fever and accompanying asthma will be greatly 
benefited, and in many instances cured. 

As regards the medicinal treatment of cases that 
have '.nore or less asthma during the haj-fever sea- 
son, the use of the suprarenal gland, both internally 
and in the form of spray, will be found of service, by 
improving the tone of the nasal and bronchial 
mucous membrane. Mention might also be made 
of the smoking of stramonium leaves. The dried 
stramonium leaves, as found in the shops, when 
smoked in a pipe, are kept ignited with considerable 



96 



MEDICAL RECORD. 



[Jiily i6, 1904 



difficulty. A good way to remedy this condition, is 
to separate the leaves and soak them thoroughh' in 
a saturated solution of nitrate of potassium, then 
place them on a dish in the oven until thoroughly 
dry. After being thus treated, the stramonium 
leaves will burn much more readily, besides obtain- 
ing whatever therapeutic advantage there may be 
in the use of the nitrate of potassium. 

When severe paroxysms of asthma occur, com- 
pound spirit of ether is of service. 

ror the relief of the bronchitis, which is often very 
annoying, the following medicines will be found 
useful: hydrastis canadensis, terpine hydrate, and 
cubebs. Dr. Saenger of Magdeburg (editorial, New 
York Medical Journal, May 15, 1897) recommends 
the use of the fluid extract of hydrastis canadensis 
in doses of from twenty to thirty drops four times 
a day, in chronic bronchitis with an irritating cough. 
I have, myself, found this remedy beneficial. Hare 
states that terpine hydrate is of value in the bron- 
chitis of hay-fever, by increasing the production of 
mucus. Cubeb troches are useful and convenient. 

One of the drugs which is not much used, but 
which will often give temporary relief in hay-fever, 
is camphor. It can be administered either by olfac- 
tion or internally. It has a tendency to relieve the 
congestion and sneezing and to diminish the watery 
running of the eyes and nose. Its use has an addi- 
tional advantage, in that it has a tendency to quiet 
nervous irritability, which is at times a marked 
symptom in hay-fever patients. Internally, it can 
be given in the form of spirit of camphor, five drops 
every fifteen minutes for the first hour, and repeated 
at longer intervals as required. It should be given 
well diluted in water. 

Aside from medicinal treatment, one of the best 
methods of obtaining relief from the disagreeable 
symptoms of hay-fever, is the cold spinal douche, 
for from fifteen to thirty seconds, at a pressure of 
from twenty to thirty pounds to the square inch, at 
a temperature of 60°. This acts as a powerful tonic 
to the central nervous system. It also relieves the 
congestion in the nose in a reflex manner, by in- 
ducing the contraction of the capillaries in the nasal 
mucous membrane. The beneficial effects thus ob- 
tained may last for two or three hours, or longer. 
Th« cold plunge, shower, or cold sponging may be 
used, but the results obtained are not so favorable 
nor so lasting. There are few patients who cannot 
soon become accustomed to the douche, if properly 
administered and followed by a brisk rub. If an 
apparatus for giving the douche is not at hand, 
water from a pail should be dashed over the patient's 
back, the operator standing at a distance. 

Another excellent method of obtaining consider- 
able relief from the nasal congestion and asthma is 
the use of the ice-bag. The ice-bag is to be partially 
filled with cracked ice, the pieces being about as 
large as a white walnut, and then applied to the back 
of the neck and the upper fourth of the spine. The 
ice-bag should be kept in this position for ten or 
fifteen minutes, and then removed. If the applica- 
tion is made as above directed, the relief of the 
symptoms characteristic of hay-fever is very marked 
and lasts for several hours. It may be used two or 
three times a day without untoward symptoms. If 
applied at night before retiring, the nasal and 
asthmatic .symptoms will be much relieved, so that 
the patient will be able to get several hours' quiet 
sleep. 

A large number of hay-fever patients find a change 
of climate beneficial. Most patients are greatly 
improved by a sojourn in the mountains, and some 
obtain absolute relief. Others find benefit at the sea- 



shore, and by bathing in the ocean. The benefit 
derived from the surf bathing is not merely due to 
the stimulant and astringent effect of the salt water, 
but also to the force with which the water enters the 
nostrils, acting in a mechanical way, by inducing the 
contraction of the capillaries and dilated veins. 
The beneficial effect resulting from a bath in the surf 
is often marked and lasts for hours. Care must be 
taken, however, not to remain in the water too long, 
or after the patient begins to feel chilh\ for by so 
doing the results sought for will not be obtained to 
their highest degree. 

The ocular symptoms in ha3'-fever are often very 
annoying. There is apt to be more or less conjuncti- 
vitis, which may be rendered more intense by strong 
sunlight and the irritation of dust. There maj^ be 
considerable lacrymation and the secretion may be 
very irritating. For this it is well to use Agnew's 
eye- water three times a day (boric acid grs. 10, 
camphor water, i oz.). I would also recommend 
that hay-fever patients wear tinted glasses during 
the active period of the exacerbation, as at times 
the reflex action of the bright sunlight on the eyes 
induces attacks of sneezing, which still further in- 
creases the nasal congestion. Thej' also protect the 
eyes to some extent from irritating dust. 

In the treatment of hay-fever we should avoid the 
use of opium in any form. It should be used only as 
a last resort, and after all the other means, above 
advocated, have been given a fair trial. 

I would also recommend that the use of cocaine be 
avoided. We should always bear in mind that the 
cocaine habit may be formed by its use in a spray. 
In a large number of cases it will be found that the 
use of the suprarenal gland, both internally and 
locally, will give as much relief as was formerly 
obtained by the use of cocaine. 

Patients should be advised to abstain from the use 
of tobacco during the exacerbation of hay-fever. It 
has a tendency to produce irritation of the mucous 
membrane of the respiratory- tract and to aggravate 
any chronic inflammators' condition that may exist. 

We should a so advise our patients not to indulge 
in alcoholic stimulants. 

In giving directions to our hay-fever patients con- 
cerning their diet, mode of life, etc., it will be well to 
instruct them to avoid walking too fast and getting 
overheated, especially if the weather be warm and 
damp or foggy, as under these circumstances 
asthmatic symptoms are apt to be aggravated. 
They should also be cautioned against cooling off too 
quickly, or exposing themselves to draughts. 

Patients should be advised to avoid driving in the 
dust, if discomfort is experienced thereby, such as a 
paroxysm of sneezing and increased nasal congestion. 
I know of one case, and have been informed of an- 
other, in which the smell of the sweat from the horse 
when out driving wou d cause great nasal congestion 
and discomfort. The first of these patient's could 
ride in a trolley car or railway car without dis- 
comfort, showing that it was not merely the dust 
that set up the irritation. 

In concluson. I would say that, if the patient can 
be induced to live in a hygienic way as re.gards diet, 
baths, ventilation of sleeping room, exercise, etc., 
and will carefully carry out the directions of his 
physician, his attack of hay-fever will be consider- 
ably mitigated; and his condition will be still 
further ameliorated if he can be persuaded to submit 
to the necessary rhinological treatment, as pre- 
viously outlined. With patience and perseverance 
on the part of both phj'sician and patient, it is 
certain that considerable and, in some cases, lasting 
benefit may be obtained as the result of treatment. 



July i6, 1904] 



MEDICAL RECORD. 



97 



Medical Record: 

A Weekly Journal of Medicine and Surgery. 



GEORGE F. SHRADY, A.M., M.D., Editor. 

THOMAS L. STEDXIAM, A.M., M-D., Associate Editor. 



PUBLISHERS 

WM. WOOD & CO., 51 , Fifth Avenue. 

New York, July 16, 1904. 

IMMUNITY AGAINST INFECTION IN ABDOM- 
INAL SURGERY. 
The prevention of infective disease maj' be effected 
in one of two ways, either by offering an obstacle to 
the entrance into the organism of the offending 
microbe, or by so strengthening the powers of 
resistanceof the organism that it isable successfully to 
repel the microbic invasion. The same principles 
should apply in the domain of operative surgery, 
since postoperative wound infection is entirely 
analogous in origin to pneumonia or diphtheria, and 
in fact we see that they do apply. But in general 
surgery the first of the two modes of prevention just 
mentioned, that of exclusion of the germs, is so 
simple in execution and so certain in result that a 
resort to the less simple and less certain preventive 
inoculation would be unjustifiable in most cases. 
Indeed this method of treatment, which may be 
called the Jermerian in distinction from the Listerian, 
has hitherto, with few exceptions, been confined to 
the prevention of tetanus, unless we may regard the 
Pasteurian treatment of threatening rabies as a sur- 
gical measure. 

There is one extensive field of surgical endeavor, 
however, in which the application of antiseptic prin- 
ciples, while of course not altogether useless, is 
uncertain in its results because of the impossibility 
of sealing the wound so as to prevent a subsequent 
invasion by pathogenic microorganisms. This field 
is the abdomen. Here then is an opportunity to ap- 
ply the Jennerian principle in surgery — but how? 
Manifestly we cannot immunize against the colon 
bacillus by antistreptococcus serum, nor against 
Staphylococcus pyogenes by immunization with a 
strain of Bacillus coli.and it is even doubtful whether 
we could protect against all the strains of the colon 
bacillus by a single serum. This being the case, the 
problem of the prevention of peritonitis after ab- 
dominal operations must be attacked in another way. 

One possible solution of the problem was the sub- 
ject of a very interesting discussion by Professor von 
Mikulicz-Radecki of Breslau in the Cavendish 
Lecture which he delivered before the West London 
Medico-Chirurgical Society on June 24 {The 
Lancet, Jul}' 2, 1904). After rejecting the suggestion 
of a specific serum and showing the impossibility of 
disinfecting the mucous membrane of the stomach 
and intestine preparatory to operation, he said that 
the only resort of the surgeon was to increase the 
power of resistance of the peritoneum against in- 
testinal bacteria by producing an artificial leucocy- 
tosis. A number of investigations have shown that, 
whether the bacteria are destroyed by active 



phagocytosis alone, or whether the leucocytes pro- 
duce alexins which kill the bacteria outside the cell 
body, or whether those two processes work together, 
general leucocytosis certainly does play a very im- 
portant part in the struggle against bacteria. 

This condition of hyperleucocytosis has been in- 
duced artificially by injections (intraperitoneal or 
subcutaneous) of alburaose, decinormal saline solu- 
tion, bouillon, nucleic acid, and tuberculin. Of these 
Mikulicz and his clinical assistant, Miyake of Japan, 
obtained the most satisfactory results with nucleic 
acid. They found that by subcutaneous injections 
of nucleic acid inguinea-pigs, it waspossible to increase 
the resistance of the peritoneum to such an extent 
that even a considerable quantity of intestinal con- 
tents could be placed in the peritoneal cavity with- 
out causing damage, but without previous treatment 
an acute, rapidly fatal peritonitis followed almost 
without exception. 

The result of these experiments was so satisfactory 
that a practical application of the method was em- 
ployed in man . A two-per cent, solution of nucleic acid 
was employed and about 50 c.c. was injected beneath 
the skin of the chest. In the experiments upon 
guinea-pigs the optimum hyperleucocytosis occurred^ 
about seven hours after the injection (the immedi- 
ate effect during the first hour or so was a hypoleuco- 
cytosis), but in man this occurs somewhat later, and 
Mikulicz has therefore determined upon twelve 
hours as the proper interval between injection and 
operation. This ensures that the operation will be 
performed at the time of the rising tide of leucocy- 
tosis. 

The proof of a theory lies in its practical working, 
and the satisfactory demonstration of this can be 
furnished only by a large number of cases in the 
hands of many operators. The results of Mikxilicz's 
own cases, however, are such as to encourage others 
to make a trial of his method. He gave the in- 
jections preliminary to forty-five casesof laparotomy, 
in which the peritoneum was exposed to infection by 
the contents of the stomach, intestine, or bile ducts. 
Of the patients operated upon, thirty-eight re- 
covered, and of the seven deaths, not one was due to 
peritonitis. In most of these cases, in addition to the 
injections of nucleic acid, the further precaution was 
taken to flush the peritoneal cavity with warm 
decinormal saline solution, and it is very possible 
that that contributed, in some measure, to the success- 
ful outcome, as saline irrigations are known to in- 
crease the resisting power of the peritoneum. 



THE MEDICAL MAN'S VACATION. 
The opinion lateh' expressed by a financier, 
noted for personal economy, that vacations 
are needless and not beneficial to health, 
has aroused a considerable amount of interest in 
the matter. Not that the views of the New York 
millionaire are considered seriously, but because 
the time for taking holidays has come and the sub- 
ject is alwajrs worthy of discussion. No one reaUy 
thinks that vacations are unnecessary evils, and 
that a cessation from work and a change of air and 
scene are not for the good of toilers. The majority 
of people will continue to take an annual holiday, 
and furthermore will derive benefit therefrom to 
body and mind. All dwellers in great cities require 
a temporary respite from the noise and turmoil of 



98 



MEDICAL RECORD. 



[July i6, 1904 



the crowded streets, and a period of rest or dis 
traction from the exciting or monotonous routine of 
daily business. There are indeed some who by 
reason of their poverty are unable to get away from 
the town, but are doomed from year's end to year's 
end to exist among wretched surroundings, com- 
pelled by an unhappy fate to labor unceasingl}'. 
No one, however, who knows the inhabitants of the 
tenement districts, will not say that a stay in the 
countrj' would do them good. In fact, it may be 
laid down as an axiom that to those who live in 
modern towns, a vacation is more or less of a neces- 
sity. This statement may be made with greater 
truth of members of the medical profession than 
those of any other class. 

The recommendations as to holidays are widely 
different. Some advise a long holiday, others a short 
holiday two or three times a year. One lays stress 
upon the importance of fresh air and a change of 
scene, anothei holds the view that sight-seeing 
should be strictly eschewed, while yet another will 
assert that two or three weeks in bed is the most 
sensible manner of spending a vacation. Lastly, 
there is the crusty exponent of materialism, who 
thinks that the vacation idea is entirely a weariness 
to the flesh and a vexation of spirit, a needless ex- 
pense for no adequate return, and a grave mistake 
in most respects. Quot homines tot sententicB. In such 
jeremiads there is undoubtedly a.'substratum of truth, 
insomuch as vacations seldom come up to expecta- 
tions, and some are total failures. Nevertheless, al- 
though perhaps the ideal holiday is seldom or ever 
found, it does not alter the fact expressed before, 
that a yearly vacation is needed by every worker, 
and by no worker more than by the medical man. 

The medical profession is, on the whole, the least 
holiday-making of all the professions. Not a few 
medical men are literally wedded to their profession ; 
indeed, sometimes the knot is so tightly tied that 
they never sleep away from home, and when in bed 
usually have one ear open for the night bell. A 
great number of practitioners are perforce slaves 
to work and must content themselves with a week's 
or, at the longest, two weeks' vacation in the course 
of the year. The general practitioner, especially 
in the country, has the greatest difficulty in leaving 
his practice even for a short time. He and his 
patients are on terms of such intimate relationship, 
that, if, when the vacation time has come, those 
whom he has known for years are grievously sick, 
he is unwilling to leave them, and if he does go, de- 
parts with almost as great reluctance as he would 
leave a member of his own family under like cir- 
cumstances. 

With regard to the kind of holiday suitable to 
the medical man, it would be presumption to advise 
as well as an impossible task. Men's tastes differ 
as widely as their appearances, while the tastes of 
their wives and daughters, who must be consid- 
ered, differ even more widely. In a general way, 
however, it may be said that the town doctor will 
be happier and better "far from the madding 
crowd" in the sweet seclusion of a country retreat. 
But, although it is well to regard country life 
from its picturesque and romantic aspect, the matter- 
of-fact side of the question must not be overlooked. 
The beauties of rural scenes and of idyllic dwellings 
are too often the masks which conceal all kinds of 



evils. The moss and ivy-covered cottage in the 
woods is frequently but a whited sepulcher. Its 
drains are defective, its water impure, and its over- 
hanging creepers and surrounding woods and under- 
growth are the home of malaria-bearing mosquitos, 
and keep the health-giving sunlight from its inmates. 
Such points should not be neglected when choosing 
a place in which to spend the summer vacation. 

The country doctor, upon the theorj', or fact, that 
a change of life and scene is the best way to spend 
a vacation, should visit the haunts of his busy 
fellowmen. Perhaps there is no more healthful 
and pleasant mode of taking a holiday for the coun- 
try' practitioner than attending the meetings of the 
American Medical Association and of State and 
County Medical Societies. Such a meeting, for in- 
stance, as that which has recently taken place in 
Atlantic City afforded unbounded opportunities 
for instruction and amusement to the medical 
man. At these gatherings he meets and can 
listen to men eminent in the profession ; men 
from all countries and of world-wide reputation. 
Such communion is of inestimable advantage in 
many ways; he receives new ideas, and some of the 
rust which has gathered upon him in his necessarily 
somewhat contracted sphere of life is rubbed off. 
Over and above these advantages, the mixing in 
the social life of his equals, denied him to a great 
extent when at home, tends to enlarge his views. 
The unaccustomed stir and bustle of the town or 
of the pleasure resort stimulate his faculties, dulled 
by the monotonous routine of his daily toil, and 
elevate his entire being, so that he goes back to 
his work like a giant refreshed. The feminine part 
of his family can also participate in the social 
amusements which are a part of present-day medi- 
cal meetings with equal benefit. 



Surgical Treatment of Chronic Nephritis. 

In the Scottish Medical and Surgical Journal, for 
May, 1904. Dr. Francis D. Boyd reviews the above 
subject. The question of surgical interference in 
chronic nephritis has been greatl}^ to the front 
within recent years, and especially in this country 
has gained much ground. Dr. Boj'd says that 
Harrison seems to have been the first to advocate 
incision of the kidneys in cases in which there 
was evidence of increased tension of the organs. 
In America Edebohls has been the most prominent 
exponent of this mode of surgical procedure — indeed 
decapsulation of the kidneys is known as Edebohls'. 
operation. Dr. Boyd, referring to the publications 
by Edebohls on decapsulation of the kidneys, says: 
"As in the cases in which full details are given, 
one cannot in several instances accept the diag- 
nosis, it leaves one with an uncomfortable and 
unconvinced feeling with regard to the accuracy 
of the observer's conclusions in the tabulated 
cases." 

From a physician's standpoint, the author con- 
siders that one of the most important contribu- 
tions is from the pen of Senator. He denies the 
occurrence of one-sided nephritis unless there be 
only one kidney. Nephritis results from causes 
which are equally applicable to and equally affect 
both kidneys. After again referring to and criticis- 
ing Edebohls' views. Dr. Boyd concludes as fol- 
lows: (i) That while the kidney may undergo 
a chronic fibrosis as the result of a local cause, the 
occurrence of a one-sided kidney has not been 
proved. (2) In chronic diffused nephritis, in 



July 1 6, 1904] 



MEDICAL RFXORD. 



99 



which medical measures have been tried without 
benefit, decapsulation of the kidneys may be 
justifiable, and may be undertaken in the hope 
that relief of tension may facilitate the circu- 
lation through the kidneys, may increase urinary 
secretion, and may produce decided amelioration. 
The operation does not in itself seem to be associ- 
ated with such risk as might have been expected. 
Many of the recorded cases were in a critical con- 
dition when operated upon. The benefit in some 
was so immediate and marked that it can only 
be accounted for by the relief of tension and im- 
proved circulation through the normal channels, 
not by the formation of new paths for the circula- 
tion. (3) The contention that chronic interstitial 
nephritis i»ay be cured by operation has, so far, 
not been proved, as the cases on which the claim 
is founded are so insufficiently recorded as to 
leare the observer in considerable doubt as to the 
accuracy of the diagnosis. (4) Surgical measures 
in affections purely local and for the most part 
unilateral, such as calculus, pyelitis, pyonephrosis, 
etc., are eminently successful. In such cases the 
fibrosis in the kidney is not a true nephritis, and 
may be benefited by operation. (5) In cases of 
nephritis, in which cardiovascular changes are 
advanced, it is unreasonable to expect anything 
but amelioration of symptoms from decapsulation 
of the kidneys. 



Medical Electricity. 



Electricity used in various forins has come to 
be a valuable adjunct in medicine and surgery, 
and undoubtedly will in the course of time be a 
much more important factor in the treatment of 
diseases and injuries than it is even now. Medical 
electricity is as yet but in its infancy. Of the 
many modes of harnessing electricity to the use 
of the medical man the production of y-rays is 
the most conspicuous, and is fast taking its right- 
ful position as an almost indispensable means of 
diagnosis in certain cases. 

The Hospital of May 28, 1904, contains a resume 
of the latest literature concerning medical elec- 
tricity. Brock and Stanley Green have pointed 
out, in the Quarterly Medical Journal, that the 
x-T&y tube is of service in the more complete 
definition of diseased lung in phthisis. They have 
now had a number of cases to base their de- 
ductions upon, and declare that: (i) In no 
single case in which the physical signs have 
pointed to disease have the rays failed to detect 
the mischief; (2) In some cases in which phy- 
sical signs have been absent the rays have 
shown deposits in the lungs, and in these cases 
physical signs have subsequently been detected; 
(3) The early diagnosis is certainly helped; (4) 
Tkat the extent of the disease is in many cases 
shown to be greater than the physician thinks; 
(5) That the progress and results of treatment can 
be watched with greater accuracy. 

Chisholm Williams, in the British Medical Journal, 
gives favorable testimony as to the beneficial 
effects of high-frequency currents in the treatment 
of phthisis. In 1901 he recorded forty-three cases 
under treatment, and now of these, three have died 
of pneumonia, of tuberculous kidney, and of lar- 
daceous disease. He advises that the apparatus 
be of the most powerful available. In tubercu- 
losis of other parts, joints, etc., the best results 
have been obtained by general electrification 
combined with a high vacuum electrode used 
from the resonator, or the ordinary a;-ray dis- 
charge. Cases of old-standing tubercvdous lesions 
he states to be very amenable to treatment. In 



the treatment of lupus he finds the .T-ray tube as 
reliable and to produce as good results as the light 
treatment. He urges the use of the high vacuum 
electrodes with a vacuum high enough to produce 
fluorescence on an ,r-ray screen. Also the patient 
should receive on the condensation couch as much 
as 350 milliamperes and upward. In opening 
the discussion upon the subject of electro-thera- 
peutics in the treatment of malignant diseases, at 
the annual meeting of the British Society of Electro- 
therapeutists, Lewis Jones raised numerous ques- 
tions of the first importance which demand solution 
ere much advance can be made. Notably is this 
the case in the matter of what kind of rays are 
of most advantage — whet her the "a:-rays," "cathode 
rays," or a combination of the two. He personally 
recommends the use of a "medium" tube, and 
prefers to operate with the anti-cathode red hot. 
He avoids dermatitis by arranging the exposures 
suitably, and continues the treatment for three, 
four, or five months. 

Alan Jamieson, writing in the Lancet, in referring 
to the employment of hard or soft tubes in ar-ray 
work, states that he has found that weather affects 
the rays materially, e.g. on cold, raw days reac- 
tions more readily occur. Wild, in the Medical 
Chronicle, has grave doubts as to the prophylactic 
value of the a;-rays in preventing recurrence after 
operation for cancer. A case of splenomedullary 
leukemia reported in the Medical Record, August 
22, 1903, has been treated by Nicolas Senn with 
great success, and other similar cases have been 
since reported. 

On the whole, notwithstanding the many instances 
in which skin diseases, and even malignant diseases 
of a superficial nature, have been treated successfully 
by this means, it is as a diagnostic agent that the 
a:-rays have yielded the most brilliant results. As 
remarked before, however, we are only upon the 
threshold so far as the use of electricity in medicine 
and surgery is concerned. 



NrhtH nf tlrr Mttk. 

Enforcement of the Law Regarding the Report 
of Contagious Diseases. — Dr. Thomas Darlington, 
President of the Board of Health of this city, has 
addressed a circular to physicians, saying that 
the health authorities are very anxious to restrict 
the prevalence of infectious diseases, and increase 
the accuracy and completeness of the vital sta- 
tistics of the city, and that they intend, therefore, 
to enforce strictly the provisions of the Sanitary 
Code in regard to the reporting of contagious 
diseases and births. According to Section 133 
of the Sanitary Code, it is the duty of every phy- 
sician to report to the Department of Health, in 
writing, the full name, age, and address of every per- 
son suffering from any one of the infectious diseases 
included in the following list, with the name of 
the disease, within twenty-four hours of the time 
when the case is first seen: Contagious' (very 
readily communicable): Measles, rubella (rotheln), 
scarlet fever, smallpox, varicella (chicken-pox), 
typhus fever, relapsing fever. Communicable: 
Diphtheria (croup), typhoid fever, Asiatic cholera, 
tuberculosis (of any organ), plague, tetanus, 
anthrax, glanders, epidemic cerebrospinal menin- 
gitis, leprosy, infectious diseases of the eye (tra- 
choma, suppurative conjunctivitis), puerperal sep- 
ticjemia, erysipelas, whooping-cough. Indirectly 
communicable (through intermediary host) : Yel- 
low fever, malarial fever. 

The American Medical Association in 1905. — 
The date set for the next session of the American 



lOO 



]\IEDICAL RECORD. 



Quly 1 6, 1904 



Medical Association is July 11-14. 1905. This 
date has been decided on after considerable corre- 
spondence. The holiday season for the majority 
of medical men is from about the first week in July 
to September, and the schools have by that tirne 
all closed. Most of those who live in the east will 
want to utilize the trip to the association meeting 
as their summer vacation, and if the date were that 
usually adopted for the association meeting, these 
would not be able to attend. In July Portland 
has a delightful climate, and consequently there 
need be no fear of hot weather. — Journal of the 
American Medical Association. 

The White League of Pennsylvania has bee'^ 
chartered for the purpose of providing open-air 
treatment for patients suffering from tuberculosis 
and unable to provide for themselves. A farm 
has been secured in Luzerne County, near Glen 
Summit, where a permanent camp will shortly be 
built. A temporary camp will soon be opened 
at Trout Run, near Bethlehem, with provision 
for ten patients. In addition to the camp a hos- 
pital is to be built on high ground about ten miles 
from Philadelphia. 

Cholera is epidemic in Teheran, Persia, the deaths 
numbering several hundred daily. One of the 
recent victims was a New York merchant who has 
resided there several years. Dr. Allen, the American 
minister at Seoul, reports that cholera has ap- 
peared at An Tung, and that both of the belligerent 
armies in Manchuria are in great danger from the 
spread of the disease. The health authorities in 
Russia fear that the disease may invade their 
country from one or both of these sources, and 
precautions are being taken to prevent such a 
calamity. 

Report on Cancer. — The committee of the Cancer 
Research Fund made a report at the annual meeting 
held in London last week. Some of the assertions 
made are rather too dogmatic and positive, as 
transmitted by cable, to preserve an altogether 
scientific tone, but doubtless the condensation of 
the reporter is accountable in part for that. The 
committee said that cancer was not caused by a 
parasite and was not transmissible from one person 
to another. It was denied that cancer was on 
the increase, and the effect of civilization on the 
incidence of the disease was declared to be nil, since 
animMs were sufferers equally with mankind. It 
was declared that radium had no therapeutic 
influence on malignant growths, but hope was 
held out that curative results might be obtained 
from a serum which the committee had elaborated. 
Newport, Ky., Branch Hospital. — In a decision 
handed .down July 8 by Judge Berry in the Circuit 
Court, the city of Newport is restrained and en- 
joined from locating or maintaining within a mile 
of the boundary lines of the Coldspring District 
any branch hospital or institution where cases of 
contagious disease may be treated. It was thought 
that the location of the branch hospital on the 
Alexandria pike, about five miles out of Newport, 
had proved a solution to a very vexing problem. 
Four thousand dollars was paid for the ground and 
house, and about $1,000 was expended in fitting 
the place up, after numerous other attempts to 
locate a branch hospital had proved futile, because 
of the hostility of persons residing in the vicinity. 
The city will probably take an appeal. 

The Association of Surgeons of the Baltimore 
and Ohio Railway met in the parlors of the Hamilton 
Hotel in St. Louis, June 29, 30, and July i. At 
the meeting Dr. H. B. Stout of Parkersburg, W. Va., 
introduced a measure to secure the cooperation 



of the surgeons in a general plan to give lectures 
and instructions to conductors, engineers, brake- 
men, and firemen at all division points regarding 
the treatment of injured persons. Officers elected 
were as follows: President, H. Slicer Hedges of 
Brunswick. Md.; Vice-President, N. R. Eastman of 
Belleville, Ohio; Secretary-Treasurer, G. A. Davis 
of Summit Point, W. Va. 

Joint Meeting of the International Association 
of Railway Surgeons and the American Academy 
of Railway Surgeons. — A joint meeting of these 
two societies was held in Chicago. 111., June i, 
2, and 3. The convention met in the Assembly 
Hall of Northwestern University. During the 
first day the sessions were presided over by Dr. 
James H. Ford of Indianapolis, President of the 
International Association of Railway Surgeons, 
and the sessions of the second and third days by 
Dr. S. C. Plummer, President of the American 
Academy of Railway Surgeons. An address of 
welcome was delivered by Dr. Wm. A. Evans of 
Chicago, which was responded to by Dr. George 
Ross of Richmond. Va. President Ford discussed 
the "Use and Abuse of the Railway Surgeon" in 
his presidential address; and President Plummer 
selected, as the title of his address, "Following 
and Assisting Nature." Many papers were read 
and discussed. A resolution was introduced and 
adopted vinanimously to the effect that the Inter- 
national Association of Railway Surgeons dis- 
solve its present organization for the purpose of 
organizing the American Association of Railway 
Surgeons, provided that a union be made with the 
American Academy of Railway Surgeons; and 
also that the executive board of the International 
Association of Railway Surgeons be authorized 
to join with the executive board of the American 
Academy of Railway Surgeons and organize the 
American Association of Railway Surgeons. The 
following are the officers of the new organization, 
the American Academy of Railway Surgeons: 
President, Dr. John E. Ow^ens, Chicago, 111.; Vice- 
Presidents, Dr. R. W. Corwin, Pueblo, Col.; 
Dr. G. D. Ladd, Milwavikee, Wis., and Dr. H. C. 
Fairbrother, East St. Louis, 111.; Treasurer, Dr. 
T. B, Lacey, Council Bluffs, Iowa; Secretary, Dr. 
H. B. Jennings, Council Bluffs, Iowa; Editor, 
Dr. Louis J. Mitchell, Chicago; Executive Beard: 
Drs. D. S. Fairchild, Des Moines, Iowa, and A. I. 
Bouffleur, Chicago, three-year term; Drs. S. C. 
Plummer, Chicago, and A. L. Wright, Carroll, 
Iowa, two-year term; and Drs. W. S. Hoy, Wells- 
ton, Ohio, and J. R. Hollowbush, Rock Island, 
111., one-year term. There was considerable dis- 
cussion relative to the time for holding the next 
annual meeting, but this matter was left entirely 
to the executive board. It is probable that the 
meeting will be held next year some time in the 
autumn. 

New Jersey State Medical Licentiates. — At the 

meeting of the State Board of Medical Examiners 
of New Jersey, held at Long Branch, Juh' 5, forty- 
three candidates for a State medical license, who 
passed the examination at Trenton on June 21-22,. 
were licensed. The candidates represented twenty 
medical colleges located in Boston, New Haven, 
New York City, Brooklyn, Syracuse. Philadelphia, 
Baltimore, Washington, Chicago, Toronto, . and 
-Naples, Italy. The following attained the Honor 
Roll, or a general average of 90 and upward: 
Dr. Louise Martha Sturtevant, A.B. of Wellesley, 
and M.D. of Boston University- Schr^ol of Medicine,, 
attained 91.6; and Dr. Henr>' Augustus Craig, M.D., 
of Columbia University, attained 90.7. The fol- 
lowing Officers were elected for the ensuing year: 



July 1 6, 1904] 



MEDICAL RECORD. 



lOI 



President, Dr. William H. Shipps, Bordentown; 
Secretary, Dr. E. L. B. Godfrey, Camden; Treasurer, 
Dr. Charles A. Graves. 

Ohio State Board Examinations. — The Ohio State 
Board of Medical Registration and Examination 
announced on July 5 the result of the recent ex- 
amination. Out of 222 candidates 210 were 
found to be entitled to a license. Of these, 39 
reside in Cincinnati and 30 in Cleveland. 

Agitation for a New Milk Law in Chicago. — 

Dairy inspection as a means to insure a pure milk 
supply for Chicago is not considered strong enough, 
as the Chicago Milk Dealers' Association, in a 
letter to Health Commissioner Reynolds, attacked 
the present system and made a plea for the permit 
system. The Health Department Bulletin states 
that inspectors will be sent into the country for 
the purpose of conferring with and advising the 
farmers. During 1900, with one city dairy in- 
spector, only eleven farms were inspected. Without 
a change in conditions and methods, it is not ex- 
pected that four inspectors can report upon more 
than forty-four of the 4,000 dairy farms. The 
Chicago Milk Dealers' Association believes in 
trj'ing a system which has been of untold value in 
other cities. It believes that the city should re- 
quire that any one who sends milk into Chicago 
should secure the privilege and make annual 
affidavits that the sanitar}^ conditions prescribed 
by the city have been complied with. This plan is 
incorporated in a proposed amendment to the 
ordinance which provides that in applying for 
permits the dairyman furnish information re- 
garding the location of the farm, the number, 
health, and feed of the cows, the drainage, light, 
and ventilation of the stable, methods of handling 
the fresh product, and the health of the employes. 
The association also advises that the ordinance 
require shippers to seal milk cans coming into the 
city, to prevent them from being tampered with 
while on the way. Instead of fining the receivers of 
the unsealed cans, as is the present rule, this new 
arrangement would place the punishment where 
it belongs, and make the shipper suffer for the 
negligence. 

International Electrical Corgress of St. Louis. — 
An International Electrical Congress will be held 
in St. Louis, during the week September 12 to 
17. The congress will be divided into two parts, 
namely, (i) A chamber of government delegates 
appointed by the various governments of the 
world, invitations to which were issued at the 
beginning of the j'ear from the United States 
Government. The transactions of the Chamber 
of Delegates will relate to matters affecting inter- 
national questions of electrical units, standards, 
and the like. (2) The congress at large, divided 
into eight sections, one of which is for electro- 
therapeutics. The chairman of this section is 
Dr. W. J. Morton, New York Cit}-, and the secre- 
tary is Mr. W. J. Jenks of New York City. Three 
hundred and forty-three official invitations were is- 
sued some months ago to well-known workers in elec- 
tricity, inviting papers for the congress. One 
hundred and sixty-eight of these invitations were 
issued to persons residing in countries outside 
of North America. As a result of these invita- 
tions, 105 American and 59 foreign specially pre- 
pared papers are promised to the congress. Of 
these, 5 foreign and 15 American papers are in the 
section on electrotherapeutics. 

The Late Dr. William E. B. Davis.— The Southern 
Surgical and Gynecological Association proposes 
to honor the memorv of its founder. Dr. W. E. B. 



Davis, late of Birmingham, Ala., by erecting a bronze 
statue of him. The statue will be unveiled at 
the meeting of the association in Birmingham, 
December 13 to 15, 1904. 

American Academy of Ophthalmology and Oto- 
laryngology. — The ninth annual meeting of this 
society will be held at Denver, August 24-26, 1904, 
under the presidency of Dr. Edward Jackson of 
Denver. The secretary is Dr. Derrick T. Vail of 
Cincinnati. 

The Germantown Hospital, Philadelphia, has, by 
the gift of Anna T. Jeanes, come into possession 
of a handsome residence on Locust Avenue, near 
Chew Street. The income from the rental or 
sale will be devoted to the purposes of the hospital. 
Ground has been broken for the erection of a 
laboratory adjoining the hospital at a cost of 
$2,500. This is the gift of Mr. John D. Mcllhinny, 
in memory of an infant daughter. The building 
will be one-story high and will be used for patho- 
logical and bacteriological investigation. A new 
building for pay patients, erected at a cost of 
$100,000, raised by popular subscription, will be 
ready for occupancy in the latter part of July. 
It is a three-story fire-proof structure, containing 
twenty-five private rooms and a special operating 
room. 

Home for Nurses at Jewish Hospital. — The con- 
tract for the construction of the Nurses Home at 
the Jewish Hospital, Cincinnati, has been let. 
The building will be three stories in height and 
cover a plot of grotmd measuring 35 feet front, 
with a depth of 67 feet. It will be built of brick, 
with trimmed stone dressing. 

A School in Philanthropy. — The success of the 
summer school in philanthropic work, which has 
been in operation in this city for seven years, has 
been so great that a permanent school of that 
character is to be established. The first session 
will begin early in October under the direction of 
Mr. Edward T. Devine. 

Dr. Adam Szwajkart has been appointed by 
Governor Yates a member of the West Park Board, 
to represent the Sixteenth Ward. He is a graduate 
of the University of Cracow, and of the Medical 
Department of the University of Illinois. 

Erection of New Hospital. — Within a few months 
the Columbus Hospital at Lake View Avenue and 
Deming Place, Chicago, which is under the manage- 
ment of the Missionary Sisters of the Sacred Heart, 
will be erected, sufficient funds having been al- 
ready received to insure the success of the venture. 
The hospital will be five stories in height, and will 
be equipped with 150 rooms and 20 nurses. 

Hamilton County, Ohio, Coroner's Report. — 
There were 103 suicides in Hamilton County during 
the year ending June 30, according to the annual 
report of Coroner Weaver. Of these all were 
white, with the exception of two colored women. 
It is a matter of record that few negroes commit 
suicide. Coroner Weaver also investigated 32 
homicides and 358 accidental deaths. His atten- 
tion was called to 334 deaths due to natural and 
unknown causes. Seven persons died from alco- 
holism and the inquests aggregated 834. 

A New Journal. — The Missouri State Medical 
Association has decided to publish its transactions 
in the form of a monthly medical journal and the 
initial number of the Journal of the Mtssotiri 
State Medical Association appeared on July i. 
Dr. C. M. Nicholson is editor, assisted by Drs. 
C. Lester Hall, F. J. Lutz, Woodson Moss, M. P. 
Overholser, Robert T. Sloan, and L. A. Todd. 



I02 



:\IEDICAL RECORD. 



[July 1 6, 1904 



Professor Hofifa of the University of Berlin 
delivered a lecture in Germany's section of the 
Educational Exhibit at the World's Fair in St. 
Louis, on June 25. The subject of the lecture was 
Coxa Vera, and it was elaborated by some beautiful 
specimens and excellent radiographs. About fifty 
leading St. Louis physicians attended the lecture 
and a banquet which was given later in honor of 
Professor Hoffa. 

Dr. Elias Potter Lyon of the department of 
physiologj' and dean of the medical department of 
the University of Chicago has resigned his position 
to become head of the department of physiology 
in the medical department of St. Louis Univer- 
sity. 

Anti-Spitting Ordinance. — Moline, 111., has adopted 
an anti-sjiitting ordinance, with penalties varying 
from one to five dollars for its violation. Signs 
are to be posted to warn the strangers, the care- 
less, and the unwary against inadverently spitting 
on sidewalks. 

Coroner's Fees Inadequate. — The County Officials 
of Hamilton County, Ohio, have recently gone back 
from the salary system to the old fee system. 
This is welcome to most of them, but in the Coroner's 
office the salaries amounted to $8,100, while the 
annual fees amount only to about $4,100. The 
Coroner, Dr. Weaver, is searching the statutes for 
relief. 

The Chicago Hospital. — The Chicago Hospital 
Building Company, a corporation formed to build 
the Chicago Hospital at 452 Forty-ninth street, 
has given a deed of the property to the Chicago 
Hospital for a consideration of $135,000. The 
property is located no feet east of Cottage Grove 
avenue, and has a frontage of 75 feet and a depth 
of 132 feet. The improvement consists of a five- 
story brick building. The transfer was made sub- 
ject to an incumbrance of $30,000, and the grantee 
has given a trust deed to the Merchants' Loan and 
Trust Co., to secure an additional loan to John 
T. Binkley of $40,000 for five years at 5 per 
cent. 

A New Sanatorium at Denver. — The Agnes Memo- 
rial Sanatorium, for the treatment of pulmonary 
tuberculosis, was opened on Julj'' 2, Denver, with 
fitting exercises. The sanatorium was built and fur- 
nished by Lawrence C. Phipps in memorj' of his 
mother, Mrs. Agnes Phipps. 

The California Vaccination Law. — The Supreme 
Court of California has reaffirmed the constitu- 
tionality of the "act to encourage and provide 
for a general vaccination in the State." The de- 
cision was rendered in a case referred from the 
county of San Diego, where the antivaccina- 
tionists have been creating no little trouble for the 
school board. 

St. John's Hospital Made Free.— The board of 

managers of St. John's Hospital, in Brooklyn, 
which is under the control of the Church Charity 
Foundation of the Episcopal Diocese of Long 
Island, have decided that after July i, no more 
pay patients will be admitted to the institution. 
Hereafter the work is to be of a purely benevolent 
nature. The number of patients for the present 
will be limited to the number of endowed beds. 

"The Medical Digest" is the name of a new 
journal published in Portland, Me. The editors 
are Dr. Ralph Opdyke of New York and Dr. Eugene 
D. Chelbis of Portland. The paper is to appear 
monthly, the first number being dated April, 1904. 
The early issues give promise of a useful and 
successful periodical. 



OUR LONDON LETTER. 

(From Our Special Correspondent.) 

BIRTHD.W HONORS FASHION.\BLE BAZ.\AR FOR VICTORIA 

children's hospital HARVEIAN ORATION RETURN 

CASES OF DIPHTHERIA AND SCARLET FEVER POST- 
OPERATIVE VENTRAL HERNIA ST. GEOEGE's HOSPITAL 

SLADEN .MEMORIAL OBITUARY. 

London, June 24, igo4. 
To-DAY the King's birthday is officially celebrated and a 
list of honors conferred on the occasion was issued last 
night. Among them Mr. C. Holman, the zealou.s treasurer 
of Epsom College, and Dr. Thos. Stevenson, Home Office 
Analyst, receive knighthoods. In the order of the Bath. 
Deputy Surgeon-General Thornton, I. M.S., C.B., and 
Surgeon-General Townsend, C.B., become K.C.B. Sur- 
geon Ligertwood, formerly surgeon Royal Hospital, 
Chelsea, and Surgeon-General Fawcett, Army Medical 
Staff, receive the C.B. 

The Queen was present for about an hoiu- at the opening 
of a grand bazaar at the Albert Hall on Tuesday, in aid 
of the Victoria Hospital for Children, and subsequently 
sent a letter to the president, congratulating him on the 
beautiful appearance of the hall. The sight has been 
described as "Fairy land in London," the stalls and 
decorations illustrated nursery rhymes and, of course, the 
assembly of ladies was most brilliant. On Wednesday 
Princess Louise, Duchess of Argyle, opened the second 
day's sale. Yesterday the sale concluded and a grand 
ball was held in the evening. Over £15,000 was realized, 
and after all expenses I hear the hospital will receive about 
£11,000. 

The Harveian Oration at the Royal College of Physicians 
was deUvered on Tuesday, by Dr. Richard Caton of Liver- 
pool. He divided his discourse into two parts. The first 
dealing with Egj'ptian medicine, in which he gave an 
account of some of the results which archaeological research 
has arrived at, in reference to the dawn of medical prac- 
tice. About 3500 years B. C, the medicine-god, I-em- 
Hotep, whose name means "he who cometh in peace, " was 
probably a priest of Ra, physician and sun god. From 
inscriptions and papyri his temples, where healing 
was carried on, were, in fact, hospitals. The later 
Greek colonists called them asklepieia. His priests also 
practised embalming and so acquired definite anatomical 
ideas. In the Ebers papyrus is a passage which the 
orator quoted as "wise advice," the importance of which 
we have, he suggested, scarcely as yet recognized. It was 
to the effect that in heart disease, if possible, the heart 
should be made to rest somewhat, and with this I pass by 
many interesting remarks to the second subject of Dr. 
Caton's able oration. This wa^ devoted to the prevention 
of valvular disease. Why do rheumatic joints recover 
and the endocardium not? asked Dr. Caton, and replied, 
because the joint can rest but the heart cannot intermit 
its labors. But it may be made to rest partially, and this 
has been his practice for twenty years. He enjoins 
absolute quiet, the patient to lie with head at low level, 
made as comfortable as possible, encouraged to sleep, no 
excitement being permitted, and pain or fever being sub- 
dued — in short, he seeks to attain the nearest possible 
approach to physiological rest, as enjoined by our Egyp- 
tian predecessors thousands of years ago. We may add 
iodides to promote absorption of exudations but chiefly 
to lower tension, as in aneurysm. Of this plan Dr. Caton 
spoke most confidently, after carefully following it for 
over twenty years. 

Dr. A. Newsholme read a paper at the Medical-Chirurgical 
Society on protracted and recrudescent infection in diph- 
theria and scarlet fever. Protracted infection in diphtheria 
was recognized by Greenhow and Gresswell, but not until 
recently has it been observed in scarlet fever. It doubt- 
less occurred before the period of isolation hospitals, and 
Dr. Newsholme would explain by it the persistent belief 
in the infectiousness of late desquamation. He examined 
the explanations offered of return cases.which he said were 
relatively rare, and did not invalidate the value of isolation 
hospitals. These cases were generally connected with 
otorrhoea or rhinorrhcea, though in some cases a dormant 
infection might be roused into activity by catarrh. Germs 
multiplying in the patient himself and collecting on the 
rhinorrhoeal lesion with which return cases are generally 
admitted would be more numerous than the lesser number 
that could obtain ingress from other patients. That in- 
creased activity was caused by hospital aggregation was 
a mere theory borrowed from that of smallpox. In each 
case it is a theory in support of a theory. Relapses of 
scarlet fe\-er were compared with those of enteric, and these 
are not caused by fresh external infection. 

At the Gynecological Society, on the 19th inst., Mr. 
Ryall exhibited a giant myoma which had been removed 
by Mr. Jessett, although a previous attempt at another 



July 1 6, 1904] 



MEDICAL RECORD. 



103 



hospital had been abandoned. Intravenous transfusion 
was called for. The patient did well. The tumor 
weighed twenty-six pounds. Other cases were mentioned 
by those present — one in which the tumor was over 
twenty-eight pounds, another twenty-two and one-half 
pounds. 

At the same meeting, Mr. Stanmore Bishop started a 
discussion on the prevention of post-operative ventral 
hernia, of which he had had four cases in more than 350 
abdominal sections. He urged the necessity of securing 
firm union of the peritoneum, fascia and skin, as well as 
the combined tendons of the transversalis and oblique 
muscles. He discussed also the materials for sutures, 
their sterilization and preservation, and showed apparatus 
for securing these objects. 

Dr. Macnaugh ton -Jones said he usually closed the ab- 
dominal wall in the manner shown in Mr. Bishop's dia- 
gram, which was practically the plan of Noble of Phila- 
delphia, who had lately introduced another method of 
suture (diagram exhibited). The speaker closed the peri- 
toneum by a fine continuous cumoi suture, dissected the 
fascia from the rectus, and united it by continuous suture 
passing through the fascia and looping up the muscle at 
either side, before penetrating the fascia at the opposite 
side, thus closing the wound by complete adaptation or 
slight overlapping of the aponeurosis through its entire 
extent. Any apparently weak points can then be secured 
by interrvipted sutures. 

Mr. Charles Ryall said the chief thing was to be sure the 
aponeurosis was united throughout the length of the 
wound. The union of muscle would not prevent hernia; 
that of peritoneum did not add much strength though 
important in preventing adhesions. Prolonged rest after 
operation was an important preventive. 

Dr. J. J. Macau regretted the absence of those who still 
used the through-and-through suture. Since the almost 
general adoption of suture in layers, subsequent hernia 
had been less frequent and less severe. 

Professor Taylor (president) had found in the post- 
mortem room that union which seemed perfect externally 
might be incomplete on the peritoneal surface. For some 
eight or nine years he had united the peritoneum with a 
continuous suture of the verj' finest silk sterilized by 
boiling in a benzine solution. He then passed sutures at 
about one-half inch intervals through skin, fascia, and 
muscle without including the peritoneum, but before tying 
these, he imited the fascia for the whole length of the 
wound, with a close continuous suture of the same fine 
silk as used for the peritonevmi, over which, if desirable, 
a horsehair suture could be tied and passed through the 
skin. The interrupted sutures supported the fine ones 
and after ten days were withdrawn. The silk ones were 
left. He had seen indications of them two months after- 
ward. In another case, reopened after a year, they had 
completely disappeared. In only three cases had silk 
given trouble and they occurred before he used benzine. 

Mr. Bishop, in reply, said all agreed that buried sutures 
should be absorbable. Neither wire nor catgut were ; the 
latter was apt to give way, and if used of the thickness 
often tried (No. 8) was almost impossible to sterilize; if 
one could rely on catgut being germ-free the difficulty 
would be met. By his method it was easy to assure one's 
self by both sight and touch that the aponeurosis was 
properly united throughout its entire length. 

A special court of the governors of St. George's Hospital 
was held on Tuesday, to receive the report of the com- 
mittee appointed in March, 1903, to consider the desira- 
bility of removing the hospital to a more extensive site. 
There was a large attendance, and Lord Windsor presided. 
The majority of the committee were against removal but 
there was a minority report. In accordance with the 
majority, a resolution was moved "that it is not desirable 
at the present time and under existing circumstances to 
remove St. George's Hospital from its present site." It 
was urged that this site was one of the best in the world. 
On the other hand, it was argued that the hospital is spend- 
ing at the rate of ;£io,ooo beyond its regular income and 
a sale of the site would .cover that. The resolution was 
carried. A resolution that the present is not a favorable 
time to appeal for funds for rebuilding was defeated. Resolu- 
tions were carried for utilizing the new site lately acquired 
for the immediate requirements of the hospital, and au- 
thorizing negotiations for the acqtiirement of additional 
leaseholds. Just before the close of the meeting a letter 
was read from Dr. Rob Barnes offering ;£i,ooo toward the 
expenses of the medical school. 

Mrs. Percy Sladen, to perpetuate the memory of her 
late husband, Mr. Walter Percy Sladen, at one time \ ice- 
president of the Linnean Society, has undertaken to devote 
the sum of +^20,000 to the promotion of research or inves- 
vestigations in natural science, more especialh' in zoology, 
geolog}', and anthropology. Mrs. Sladen has appointed 
the first trustees of the Percy Sladen Memorial Fund — 
four in number. 



^ Edward Trimmer is a name appended to thousands of 
diplomas of the Royal College of Surgeons during the 
forty-two years he served that corporation as secretary. 
He retired in igoi. After some months' suffering from 
malignant disease he has just passed away in his seventy- 
eighth year. 

Sir David P. Ross, late Surgeon-General of British 
Guiana was M.D., Edinburgh, 1863, and M.R.C.S., 
England, 1864. The same year he entered the army 
service. Was for twelve or thirteen years in various 
medical posts in Jamaica; and his subsequent career in the 
colonial service has been distinguished. In all his varied 
positions, from a student onward, he was esteemed by 
hosts of friends and colleagues. 

The death of Mr. A. O. Mackellar, F.R.C.S., Chief Sur- 
geon of the Metropolitan police force and formerly surgeon 
to St. Thomas' Hospital, occurred on the 15th inst., at the 
age of fifty-eight. He was M.D. and M.Ch. of the Royal 
University, Ireland, i86g. He went out to serve "as 
surgeon on the ambulances sent to help in the Franco- 
Prussian. Turko-Servian, and Russo-Turkish wars, was 
made Knight of the Military Order of Merit of Bavaria, 
of the Gold Cross of Takovo, and of the order of the 
Medjivich. 

OUR PARIS LETTER. 

(From Our Special Correspondent.) 

SERPENT VENOM MILLIAMPfeREMETER FOR X-RAYS 

BREAST-FEEDING FOR THE CHILDREN OF FACTORY 

WORKERS X-RAYS IN CANCER SOCIAL ASPECTS OF 

MEDICAL CHARITY POISONING BY CAMPHOR NAPHTHOL 

DEATH OF PROFESSOR MAREY. 

Paris. June 10, 1904. 
At the Acad6mie des Sciences, Calmette recently pre- 
sented the result of his investigations concerning serpent 
venoms and their antagonistic serums. He differentiated 
two distinct substances in these venoms, one acting on 
the blood, the other on the nervous centers. The anti- 
toxic activity of an antivenomous serum is easily deter- 
mined by experiments in vitro, in which varying amounts 
of antitoxic serum 'are made to act on a constant quantity 
of the defibrinated blood of the horse or of the rat, con- 
taining a constant amount of venom. D'Arsonval pre- 
sented a milliamp6remeter intended to measure the in- 
tensity of a current circulating in an x-Ta.y tube. This 
method will make it possible to record, rapidly and 
practically, the strength of the Rontgen rays emitted by 
a tube. 

At the Academie de M6decine,in the session on May 24, 
Professor Budin made an interesting report on the neces- 
sity of breast-feeding for the children of workers in mills 
and factories. The Academy afterward indorsed this 
report and forwarded it to the Minister of the Interior. 
The figures show that among children who die under one 
year of age nearly half are overcome by diseases of the 
digestive tract. The great cause of these diseases is 
artificial feeding; therefore nursing ought to be made 
possible. The labor organizations should be prevailed 
upon to permit women to nurse their children. Professor 
Budin calls to mind the fact that the Italian Parliament 
enacted a law in 1902 that in all factories occupied by as 
many as fifty workers there should be a room for nursing. 
The Academy should, the speaker urged, express the 
opinion that in all industries and establishments mothers 
ought to be authorized to absent themselves regularly to 
nurse their children, and that creches and special rooms 
should be established near the places for work, where the 
children could be cared for and nursed. 

At the meeting of the Societe des Internes et Anciens 
Internes des Hopitaux de Paris, held May 26, Dr. Leredde 
showed two patients with epithelioma of the face, who 
had been subjected to the action of the Rontgen rays 
during only five or si.x exposures of from thirty to forty 
minutes each. The photographs of these patients, taken 
before the treatment, showed considerable epitheliomatous 
masses, situated in one case on the left cheek, in the other 
on the forehead. The presentation of the patients them- 
selves gave the opportunity of noting the disappearance 
of the neoplastic masses. Following this presentation, an 
interesting discussion arose in regard to the action of 
.%-rays on epitheliomata. Cancerous tumors in active pro- 
liferation, malignant epitheliomata, seem clearly to be 
influenced, retarded in growth, and even destroyed by the 
Rontgen rays. The hard, homy tumors, on the other hand, 
show no well-marked effect. As to the influence of the 
Rontgen rays on internal cancerous tumors, this appears 
to be rather adverse than otherwise. Indeed, Dr. Jacquet 
cited a case in which the a;-rays evidently hastened the 
death of a patient suffering with inoperable carcinoma of 
the stomach. Dr. Pechon also cited a case of non-ulcer- 
ating sarcoma of the thigh, treated by exposure to x-rays, 
which was followed by general sarcomatosis and the death 
of the patient. 

Mesureur, director-general of the "Assistance Publique," 
delivered a remarkable address, at the same meeting, on 



I04 



MEDICAL RECORD. 



Qvily 1 6, 1904 



the social r61e of the "Assistance Publique." He showed 
how, since the adoption of the altruistic ideas advanced 
by the French Revolution, the dignity of the indigent 
patient has been actually safeguarded, and how he has 
not been considered, as formerly, a dangerous element, 
and one prejudicial to society. Since the alleviation of 
misery devolves upon the "Assistance Publique" it ought 
preeminently to consider its prevention by means of 
social laws. ' Laws for the protection of the woman and 
the child give, from this point of view, an immediate and 
certain return, for in safeguarding their health and their 
capability for work, both the woman who is to be the 
mother and the child who is to be the citizen and the 
soldier of the future are protected. 

A great project, the most important, perhaps, which 
would considerably lessen the debt of the "Assistance 
Publique," is that which relates to the relief of the aged 
and incapacitated workers, and to the provision of homes 
for the superannuated. Thus Society, diminishing little 
by little the causes of misery, establishing the right of the 
individual to the consideration of humanity, will finally 
cancel its debt to humanity. And yet. no laws can wholly 
do away with misery and illness, for there will always 
remain some who are starving and some who are ill. The 
"Assistance Publique" is indeed at hand, as an automatic 
instrument, to distribute succor, to relieve the hunger of 
a day. but never, by itself, will it raise up again a being 
who has fallen. To its official efforts must be added the 
disinterested help of private individuals who will give that 
useful counsel, that moral support, which will reawaken 
dormant energy, will arouse the power for work, and 
will give assurance for the future. 

It is in the hospital that the divers forces of this charity 
can unite. The patients, in efiEect, in coming to the hos- 
pital, largely pay their social debt by constituting the 
vast field where science reaps its harvests, where all the 
youths of our scientific schools find the essential material 
for their studies. Passive and apathetic, the patients 
contribute their part to the progress which has made the 
renown of the French medical schoo so wide spread. 
The "Assistance Publique" considers that its honor lies 
not only in the fact that its hospitals afford an asylum for 
those who suffer, but also in the fact that they constitute 
a great practical school in which the country may take 
pride. It demands that the physician love these who so 
generously offer theii; sufferings as a means of instruction, 
love them in order to cure them, and also that he recognize 
in the patient a human being whom a word can console. 
It demands that these guardians of science, these intellec- 
tual giants, who have dedicated their great powers to the 
cause of healing, shall endeavor, by arousing a greater 
sympathy among men, to create a better society, with less 
of suffering and more of justice. 

At the Society of Surgery, the question of intermittent 
hydronephrosis, of which we spoke in our last letter to the 
Medical Record, was again discussed. Dr. Guinard 
then reported a case of poisoning by camphor-naphthol, 
in which a man succumbed a few minutes after its injec- 
tion into the cavity of an abscess from which the pus had 
just been evacuated. Kirmisson also cited cases in which 
camphor-naphthol injections had produced untoward 
accidents. The symptoms always take the same form, 
that is, either syncope or epileptiform attacks. Guinard 
stated as conclusion of his communication and of the dis- 
cussion which followed, that it seemed to him tlie admin- 
istration of camphor-naphthol by this method should be 
discontinued. 

Among the serious losses which the scientific world has 
recently experienced we would mention the death of Profes- 
sor Marey, member of the Academy of Medicine and of 
the Acad-cmy of Sciences, whose works on experimental 
physiology are well known. The sphygmograph and the 
cardiograph of Marey are instruments too \\'idely distrib- 
uted, too generally adopted throughout the worfd, and of 
a usage too common, for it to be necessary to lay stress on 
the great discoveries of this savant. During more than 
forty years, indeed, Marey devoted himself to the difficult 
problems of the heart and the blood-vessels. His great 
work was the development of the graphic method, that is 
to say, the direct inscription through the medium of pens 
of the biological phenomena observed. By a series of 
photographs Marey was able to study and to recognize all 
the phases of the circulation of the blood in men and in 
animals. Moreover, he made an interesting and valuable 
study of the flight of birds and of the various movements 
of their wings. 

Health Board Changes. — Commissioner Darlington has 
again shifted the assistant sanitary inspectors. Dr. Moore, 
who was sent from Queens to Richmond, two weeks ago. 
goes back to Queens; Dr. Sprague. who was sent from 
Richmond to the Bronx, comes to^Manhattan ; Dr. Murray, 
who went from Brooklyn to Queens, goes to Richmond. 
Dr. Pursall, who went from Manhattan to Brooklyn, will 
remain there one week longer. 



OUR BERLIN LETTER. 

(From Our Special Correspondent.) 

QUINQUAUD'S disease BERLIN LIFE-SAVING SOCIETY 

ECLAMPSIA AND THE NERVOUS SYSTEM INFANT 

MORTALITY FIRST REPORT OF MEDICAL SCHOOL IN- 
SPECTORS. 

Bbrliv, June 4, 1904. 
.^T the meeting of the Society for General Medicine, held 
May 16, Furbringe delivered an address concerning the 
value of Quinquaud's sign. The inquiries of many physi- 
cians had caused the speaker to give closer attention 
than before to the nature of this sign. Speaking of its 
history, he told how a teacher by the name of|Quinquaud, as- 
Maridon made known in igoo, made the following ex- 
periment with his scholars in 1893: He had them place 
the finger tips of a patient against the palm of his hand, 
and held them there a few minutes. Among the students- 
several were evidently scornful. In a little while crepi- 
tation was apparent in the phalangeal joints of the 
fingers that had been placed in position. This phenom- 
enon can be observed only in the case of drinkers, 
and then not with moderate drinkers. The degree, 
therefore, to which alcohol has been misused can be judged 
by the strength of the crepitation. Furbringe examined 
in this way five hundred patients, drawing them from, 
both the hospital and his own private practice. He 
divided those whom he examined into four groups: 
almost total abstainers, moderate drinkers, drinkers, 
and drunkards. He divided the sounds observed into 
three groups; perceptible, moderate, and strong. In 
the case of the drinkers, he found it sufficient if they placed 
two fingers only in position, the two chosen being the 
ring and the middle finger. He prepared the following 
table : 

Moderate Drinkers Drunkards 

Absent, 89.5 per cent. 10.5 per cent. 

Moderate, 72 per cent. 2S per cent. 

Strong, 41.5 per cent. 58.5 per cent. 

In brief, it may be said that in the case of the moderate 
use of alcohol, this phenomenon occurred only to a slight 
degree, and that where it was more marked, the case 
was that of a drunkard. In comparing tremor with 
this sign, Fiirbringe made the following table: 



Absent, 

Moderate 

Strong. 



Moderate Drinkers 
9i per cent. 
73 per cent. 
22 per cent. 



Drunkards 

7 per cent. 
27 per cent. 
78 per cent. 



It is evident from these tables that one can recognize a 
drunkard with greater certainty by tremor than by 
Quinquaud's sign. It is to be noticed that neurasthenia 
and hysteria influence both these phenomena. In no 
case was there any change in the joints. The phenome- 
non ceases when the subject is tired, but reappears after 
a short time. Furbringe drew the conclusion that 
Quinquaud's sign should not be taken alone in making 
the diagnosis of alcoholism, but it is of value in con- 
nection with other symptoms. 

The recently published report for 1903 of the Berlin 
Life-saving Society gives the opportunity for a few gen- 
eral remarks concerning the present situation and the 
outlook. In the ca.se of street accident or sudden illness 
in a house, the sufferer heretofore would receive help 
first from the stations established by the Red Cross So- 
ciety. There are twenty of these stations in Berlin, 
with their directors and assistant physicians, who, it is 
said, know how to make a very good practice for them- 
selves from the patients who come to the station, and 
have made inroads upon the practice of the physicians 
of the district. In spite of this, the number of stations 
established was not increased according to the demand. 
Seven years ago the Berlin Life-saving Society was 
founded by Morris von Bergmann, and this society at the 
present day has fifteen head stations, chiefly in the cities 
and in connection with the royal hospital, and also ten 
relief stations. In the latter, each physician of the dis- 
trict is on duty from two to four hours every week. 
Care is taken that one in laying claim to the help of a 
station does it but once in the cour.se of an illness. The 
Life-saving Society is doing a very great work through 
the introduction of a central station for the care and 
attendance of the sick of Berlin, concerning the great 
social and humanitarian significance of which movement 
we shall speak later. According to the yearly report, 
6,074 cases were treated in the chief stations, and 10,946 
in the relief stations. The increase since last year has 
been remarkable. A year ago union with the accident 
stations was refused by the Life-saving Society, but on 
April 19. 1903, a common agreement for first aid was es- 
tablished. 

An interesting discussion took place at the meeting of 
the Obstetrical and Gynecological Society. It had to 
do with the still unsolved problem of the cause of eclamp- 
sia. Bruno Wolf had repeated the well-known experi- 
ments of Blumenreich on animals, in which he removed 



July 1 6, 1904] 



MEDICAL RECORD. 



loS 



both kidneys from a large number of rabbits, sorne being 
pregnant, and some not. He made the following im- 
portant deductions: (i) In the case of a pregnant 
animal, both of whose kidneys have been removed, the 
foetus dies before the appearance of any ursemic syrnp- 
toms in the mother. (2) Typical uremic attacks, with 
convulsions, occur very seldom after the operation— 
twice out of seventy-four cases. Blumenreich believed 
that Wolf had overlooked the convulsions because they 
affect, for the most part, chiefly the neck rnuscles. 01s- 
hausen reported a case in which he, in spite of cutting 
off the action of the kidneys known to be failing had 
seen no convulsions. For this reason it was plain that 
the poison of eclampsia is something different from the 
uraemic poison due to extirpation of the kidneys. Mach- 
enrodt had seen a similar case, and Olshausen instanced 
the fact that in the end stages of carcinoma which causes 
suppression, uraemia has been observed, but not convul- 
sions. 

For the past week there has been summer weather in 
Berlin, and already the waiting rooms of physicians, es- 
pecially of those in the working districts, are full of 
■children. The mortality among infants has increased 
greatly. At the beginning of last month, much light was 
thrown on this question at a meeting of the newly-formed 
society for combating the death rate of infants. Pro- 
fessorHubner held, in this discussion, that, as a result of 
the falling off of nursing in Berlin in 1898, the mortality 
of infants had increased — and that solely because of a 
lack of patience and will power on the part of the mothers. 
While out of i.ooo living of the general population 18 
die. out of I.ooo living infants 2S6 die. Since in the 
Strahlauer Fovmdling Asylum out of 1,000 children 
only 40 die, an effort to diminish the death rate of children 
seems wise. As a return to breast-feeding will take some 
time, the thing to do now is to improve the cow's milk. 
Ostertag briefly stated the question from the patho- 
logical point of view. The milk from diseased cows is 
capable of transmitting typhoid fever and tubercu- 
losis, and may become poisonous from diseased udders, 
and also from medicines or food poisons contained in 
the milk. The milk of healthy cows may be poisonous 
when the milking is not done in a sanitary manner, or 
when the milk is not kept cool, for the bacilli which 
cause milk to sour are not killed by heat. Concerning, 
the regulation of the milk supply, Engel made the state- 
ment that in Berlin over 2,000 children were injured 
by cheap miUc. Through the action of the society many 
dairy companies have agreed to have their cows, stalls, 
etc., inspected by veterinarians and physicians. The 
director of railroads has been asked to have refrigerator 
cars for transporting the milk. Further action of the 
society has brought about the following; (i) Copies of 
regulations will be sent to dairies, physicians, infants' 
and children's asylums. (2) Midwives will be instructed 
in regard to the value of breast-feeding. (3) Notices 
from the society w^ll be sent weekly to the mothers of 
the new-bom, with a list of the inspected dairies, and with 
instructions regarding the care of milk and the feeding 
of infants. (4) .\ relief fund is to be established: (a) for 
poor mothers, so that by better nourishment for them, 
better nourishment may be assured for the children ; (6) 
in order that poor people may be able to buy better 
cow's milk ; (c) for providing for the destruction of the 
milk of diseased cow-s, after imposing a fine upon the 
dairv. (5) An agreement is to be entered into with other 
societies pursuing similar courses, and as manj- cooper- 
tors as possible won in distant places. 

How necessary the improvement in the nourishment 
of children is, was shown by a recent report concerning 
the work of the Berlin school physicians, appointed in 
the spring of the present year. Ffteen thousand children, 
recently entered in school, were examined by thirty-six phy- 
sicians. Ten per cent, of all the children were foimd to 
be physically or mentally i.mfit, and excused from school 
attendance for from one-half to one year. Of these, 25 
per cent, suffered from general physical debility, 16 per 
cent, had not overcome the results of the sicknesses of 
childhood, 5 per cent, had tuberculosis, 15 per cent, suf- 
fered from anaemia, scrofttla, or rachitis, 10 per cent, 
■were undeveloped mentally. 



A GARDEN PARTY GIVEX BY DR. LORENZ 
TO AMERICAN STUDENTS IN VIENNA. 

(From an Occasional Correspondent of the Medical Record.) 
Two weeks ago the Anglo-American Medical Association 
of Vienna — composed chiefly of American physicians who 
are studying in the various clinics in this Mecca of medical 
pilgrims — invited Prof. Dr. Adolph Lorenz to dine at the 
association headquarters and after the dinner give a lecture 
upon any subject he should elect. Dr. Lorenz accepted 
the invitation, and gave a lecture on Coxitis and his 
method of treatment. Following the lecture he spoke at 



length of his reception in America by the profession, and 
of the warm hospitality tendered him wherever he went 
while there. He next spoke of his — heretofore — inability 
to return any of that hospitality, and he took this oppor- 
tunity of extending to the members of the association an 
invitation to come to his summer home, overlooking the 
beautiful blue Danube, and attend a garden party, the 
association being privileged to set the date which would 
best conform to their convenience. The association 
acted at once upon the invitation and voted then and 
there to accept the generosity of Dr. Lorenz, and Friday, 
June 24, was set as the date. 

The weather was perfect, cool and pleasant, an ideal 
June day, the members of the association and their wives 
met at Alserstrasse station in time for the afternoon 
train which was to take them to Greifenstein-Altenberg, 
Dr. Lorenz having insisted upon bearing every expense of 
the trip for each of his guests. We reached Attenberg 
about 5 130, and were met at the railway^ station by the 
genial doctor, who greeted every one individually in the 
most gracious manner, then piloted us up a woody moun- 
tain road in the dehcious coolness and fragrance of the 
shade and odors of the flowers and shrubs, to an opening 
commanding a most extensive view of the Danube and 
its valley for many miles, and of the most glorious country 
imaginable, mountains in every direction, many of them 
surrounded by picturesque old castles, and everjTvhere 
winding in and out, "like a blue ribbon," the lovely 
Danube. . 

The rare beauty of the scene cannot be expressed in 
mere words. It burst upon our view so unexpectedly 
that we were spell-bound for several moments. Soon, 
however, our spell was broken, for as we moved on a 
little further we were greeted in the warmest and heartiest 
manner by Madam Lorenz, wife of our noted host, who 
with her sisters had arranged a booth, under a huge 
umbrella floating from the top of which were seen 
the stars and stripes of our own loved country together 
with the orange and black of Austria, Music was also 
there, furnished by a company of Vienna musicians. 
We were invited to seat ourselves upon the grass to 
rest and enjoy the beauties around us, while we were 
served with tea, coffee, seltzer and white wine, beer, cake, 
and cherries. And jkWi cherries! One could not find in any 
land more perfect fruit and more varieties. When we 
had enjoyed this pleasant refreshing for a time we were 
invited to continue our walk a little further, through 
lovely acres of currants, gooseberries and cherries, ori 
dowii to the beautiful villa of Dr, Lorenz. which nestled 
about half-wav down the mountain. Dr. Lorenz seemed 
to be everywhere, first in the fore-front, then in the rear 
and all along the line, and 'twas a long line, as we marched 
in "geese-walk" as the doctor expressed it (Ganse Marsch) 
about eighty of us — to his home. 

It would "be impossible to imagine a more cordial wel- 
come than was accorded us, as time and again our de- 
hghtful host urged us to "be at home, " "be at home. 

The villa consists of an original or old part and a very 
handsome new part. The stones of this new part have 
come entirely from old and noted Vienna buildings which 
for one reason or another have had to be taken down, and 
Dr. Lorenz bought them and had them transferred to 
his country seat, and when sufficient had been collected 
in this way he had the beautiful new part of his dwelling 
put up. the balustrade surrounding the wall and grounds 
came from an old stone bridge which crossed the Danube 
near Vienna at one time. 

The ladies were taken into the private rooms ot ttie 
house to remove their wraps, smooth out the wrinkles 
and shake off a little of the railway dust, then went out 
to assemble in the palatial hall, while the doctor '«'ith the 
professional men ascended the stairs. The guests find- 
ing places in the beautiful gallery overiookmg the hall, 
Dr Lorenz stepped forward into a little balcony and 
addressed his guests in the warmest words of greeting 
and welcome. He welcomed the wives of the physicians, 
whom he considered as representing that type of Arnencan 
woman, who, as doctors' wives, shared the hardships ot 
a doctor's Hfe. He "welcomed the two lady doctors, whoin 
he considered as that type of American woman who stood 
for woman's emancipation, and he welcomed the lady 
who as neither doctor nor doctor's wife, was known the 
worid over, and who had done so much for the profession 

Mrs, Armour — who had come out to join the Americans 

in their pleasant treat at his home. 

He spoke again of his appreciation of all the American 
hospitality which he had received, and said that it gave 
him great pleasure to welcome us as his guests. Dr. t. L. 
S«-ift, of the United States Army, responded to the word 
of welcome in a very pleasing manner. After this Ur. 
Lorenz escorted us through his house, showing us the 
various apartments, the beautiful paintings from the 
brushes of the old masters; pointing out to us, here and 
there some object of special interest. We were even 



io6 



MEDICAL RECORD. 



[July i6. igo4 



invited to inspect the kitchens, which were truly works 
of art, with their spotless tiled floors and wainscoting. 
Everything of the most approved hygienic make up, 
which, to quote Dr. Lorenz, "were of American- Viennese 
manufacture." 

The house is truly beautiful. From every window one 
found the most glonous views of the surrounding country, 
while within the arrangement of the house, its furnishings 
and hangings, proclaimed the exquisite taste and appre- 
ciation of the harmony of color of the host and hostess. 

The sixteen-months old son of Dr. Lorenz claimed (Con- 
siderable attention — a beautiful blue-e5'ed boy, strongly 
resembling his noted father, the perfect picture of health 
and happy disposition. 

We were now ushered out to enjoy the beautiful grounds 
surrounding the house, and a little later escorted to the 
tennis court, which was most perfect if its kind. Here 
we found many tables spread with snowy linen and shin- 
ing silver and flowers in profusion arranged about each 
place in a most artistic manner. Overhead were strung 
dozens of very pretty Japanese lanterns. At one side of 
the court was the dais upon which were seated the Viennese 
musicians who made music for us during the afternoon. 
They played and sang many very pretty selections during 
our meal. The supper was ser\'ed in the most attractive, 
dainty manner, and consisted of the most tempting, de- 
licious food one could wish for. Here again our interest- 
ing host and his good Frau flitted here, there, everywhere, 
among their guests, looking after each one's comfort and 
appetite in a manner delightful to see. Nothing was 
left undone that could in any way add to the pleasure 
and content of each and every guest. After the meal the 
musicians played America, whereupon we all arose and 
sang the national hymn right lustily. This was followed 
by the "Wacht am Rhein" and the Austrian national 
hymn. Professor Lorenz at this juncture presented each 
guest with a souvenir post-carte upon which was a picture 
of his villa, and for those who desired it, both he and his 
wife added their signatures. 

The tables were pushed to one side and the musicians 
began to play dance music in such an inviting manner 
that the toes of the younger members of the profession 
could not resist, and soon the scene changed to one of 
frolic and fun, which lasted until about ten o'clock, when 
the doctor's carriages drove up prepared to take the 
ladies to the railway station, a short distance away, and 
the delightful "garden party" disbanded. 

The event was certainly one in a lifetime, an afternoon 
and evening never to be forgotten by those of America's 
medical profession who were privileged to enjoy it. 

The following physicians were present : W. M. Engpl- 
bach. G. A Gardener, F. G. Harris. J L. Jacques, O. H. 
Kraft. W. H. Lambom, G P. Marquis, F. R. Morton, Brown 
Pusey, G W. Parker, H. Schafer, and J. I Wemham, of 
Ilhnois; A. E Austin, D W. Clark, F. J Hurley, D. J. Mc- 
Sweeney, A E. St. Clair, of Massachusetts; .H L. Aller, 
F. Goldfrank, Mary Sutton Macv. Isabelle Thompson 
Smart, A. W. Booth, of \ew York; E. S. Geist, D. N. Lan- 
do, H L. Williams, of Minnesota; Francis W. Alter H. W. 
Ely, H. H. Wiggers, Tubman, of Ohio; H. L. Akin, E C. 
Henry, S. J. Jones, of Nebraska; A. L. Mackenzie, E A. 
Mallon, H. G. Wertheimer, of Pennsvlvania; E. D. Clark, 
F. N. Hibben, of Indiana; Louis Ras.sicur, F. L. Stuver, 
of Missouri; E D. Chipman, Chas. Fitzgerald, of Connec- 
ticut; E. F Dodds. L. H. Fligman, of Montana; H. J. 
Schlageter, A. S. J. Smith, of California; J. J. Sullivan, 
•New Jersey; E Van Hood, Florida; S. K. Simon, Louisi- 
ana; C. E. Zerfing, South Dakota; Bernard J. O'Conner, 
Kentucky; A. C. Behle. Utah; R. P. Daniells. Wisconsin; 
R. H. Dean, Iowa; J. H. Davis, Colorado; A. W. Ives, 
Michigan; C. A. Lilly. Kansas; Walter Luttrell, District 
of Columbia; E. L Swift, United States ArmvA. H. 
Bennett, Adelaide, Australia; W. H. Gooddcn.' Bristol, 
England; A. S. Wilson, Aberdeen, Scotland. 



PHTHISIOPHOBIA. 



To THE Editor op the Medic.\l' Record: 
Sir: I have only lately read the very able plea for 
"Justice to the Consumptive" made by Dr. S. A. Knopf 
m your issue of January 2. In quoting me as opposed 
to the Goodsell-Bedcll law, I am sorry to confess that 
Dr. Knopf does me too much credit. 'Mv opposition to 
this bill was solely on accoimt of .some details that seemed 
to nie to make its operation impracticable. I am the 
rankest kind of a phthisiophobe, though no longer of 
an age or build to have any personal fear of the disease. 
Statistics show that, excluding deaths from violence 
and old ago, tuberculosis kills about a quarter of us all, 
hence us control has just about one-third of the impor- 
^^P1 °^ ^" other diseases together. A parasitic disease 
which has no necessary intermediate host, which re- 
quires no peculiar method of implantation, and which 
IS not scmelmcident.can. according to our present knowl- 



edge, be controlled satisfactorily only by the general 
principles of quarantine. 

It is straining at a gnat and swallowing a camel to 
subject patients with acute exanthematous diseases — 
which are all semelincident — to the hardships of quaran- 
tine and to allow tuberculosis patients, in the stage of 
discharge, to go free. I believe that whatever diminu- 
tion in the prevalence of tuberculosis has thus far oc- 
curred, has been due mainly to professional and lay 
phthisiophobia, and not to any considerable degree to^ 
condemnation of cattle, improvement of resisting powers, 
or therapeutic measures against the existing disease. 
I believe, also, that just as leprosy was removed from 
most European coim tries in the middle ages by enforced 
segregation, so enforced go\emmental segregation in 
sanatoria is the only promising method of dealing w4th 
the modem problem of tuberculosis. 

With regard to the exclusion of tuberculous immi- 
grants, I agree with the Surgeon-General of the U. S. 
Public Health and Marine Hospital Service that no 
immigrant should be admitted who is anj' way a menace 
to our own country. Indeed, I would go much further, 
and admit only a verj' superior class of prospective 
citizens. In other words, when the matter concerns the 
general welfare of my countrj'men, I w^ould be absolutely 
cold-blooded and selfish. 

A. L. Benedict, M D. 

156 West Chippewa Street, Bufpalo. N. Y. 



INFECTIOUS DISEASES IN PERU. 

(From Our Special Correspondent.) 

Arequipa, May 31, 1904- 
The bubonic plague seems to have taken a permanent 
hold of Lima and Antofagasta. It is probable that from 
these centers it will extend to the rest of the coast. In 
Lima the cases are not numerous and are of a compara- 
tively mild character, many of those attacked recover- 
ing and the infectivity being low. 

Hero we are having smallpox and a few cases of diph- 
theria. The former, when treated early by touching the 
papules with carbolic acid and also giving the same remedy 
or salol internally, generally doing well and leaving little 
disfigurement. 

Diphtheria, if treated early by antitoxin and a mixture 
of tincture of chlorate of iron, solution of ammonium 
acetate and potassium chlorate taken in lemonade, and 
the throat swabbed out with peroxide of hydrogen and 
glycerin, is not very fatal. The infection of diphtheria, 
may last for a long time. 

1 saw in consultation this month a boy of eight years, 
suffering from diphtheria. More than two and a half 
years previously I had seen his aimt with diphtheria in 
the same house. There was no other known or suspected 
source of infection. The house had been shut up after 
the illness of the aunt. 



The Boston Medical and Surgical Journal, July 7, 1904. 
Aciduria f(Acetonuria) Associated with Death after 
Anaesthesia. — E. G. Brackett, T. S. Stone, and H. C. 
Low report a number of cases which present certain feat- 
ures in common : Vomiting associated with collapse ; 
a very weak and rapid pulse; an absence of fever until 
just before death; cyanosis in the fatal cases causing 
extreme dyspnoea; apathy and stupor alternating with 
periods of restlessness at first, but in the fatal cases grad- 
ually deepening into coma and death; and the presence 
of acetona in the lireath and urine. In six cases the symp- 
toms came on without operation. In three of these 
cases the symptoms came on the day after entrance, and 
in one two daj's after. In one case the symptoms came 
on after the child had been in the ward for four weeks 
and was up and about. In seven cases the symptoms 
followed operation. Three of these patients died, four 
recovered. In the four milder cases the symptoms came 
on between 12 and 24 hours afterward. In the three 
fatal cases, alarming sj-mptoms came on after about 12 
hours, but in none of the cases was the recovery from 
the operation quite normal. Those children in whom the 
symptoms were severe were of high-strung, nervous tem- 
perament. The symptoms coming on after operation 
were usually more severe than those coming on without 
operation, although there was one rapidly fatal case in 
the latter group. Death in the fatal cases occurred from 
12 to 36 hours after the onset of the symptoms. It seems 
to be due in some cases to a lack of oxj-gen. Eleven 
cases showed acetonuria, and only two did not show dia- 
cetic acid in the urine, and in one of these the test %vas not 
made for it. The only marked anatomical lesion found 
in the four autopsies was the extreme fatty degeneration 
of the liver and the muscles. From the study of these 



July 1 6, 1904] 



MEDICAL RECORD. 



107 



cases it can be stated that the symptoms are not the re- 
sult of anaesthesia, operation or shock, unless in the 
presence of certain underlying causes still undetermined. 
Especially in nervous, high-strung children, the confine- 
ment, changed habits, changes in diet, homesickness, 
dread of operation, anaesthesia, and the operation itself 
may lead to changes in metabolism which have hitherto 
not been taken into account. Greater attention should 
be paid to the temperament of children entering a hos- 
pital. The absence of any gross evidence of a pathologi- 
cal condition may not constitute immunity from the dan- 
ger of acetonuria, and possible death after operation. 
Laution should be paid to those cases in which the presence 
of a fatty liver is suspected. Special care should be ex- 
ercised in those cases which show extensive degenerative 
changes, such as is seen, for example, in extensive infan- 
tile paralysis. 

Journal o] the American Medical Association, July 9, 1904. 

The Crisis and Treatment of Pneumonia. — W. J. Hal- 
braith does not offer his plan of treatment as a specific 
l)ut claims it has materially lowered his death rate. 
The hrst attention to be rendered in the ordinary cases 
is a warni bath and a saline cathartic. The indications 
governing the administration of quinine and iron are 
as follows: When the temperature has reached 105°, 
or over, 60 grains of quinine sulphate is to be administered 
as the initial dose, followed in one hour by one-half this 
amount, or 30 grains, and in another hour by one-half the 
latter dose, or 15 grains, at which time the author begins the 
administration of tincture of iron in doses ranging from 
7 to 15 minims, depending on the stage of the disease 
and the condition of the heart. If he sees the patient 
on the first or second day of his attack, he usually begins 
with 10 minims of tincture of iron, increasing it one or 
two drops, or even more, each day up to the sixth or sev- 
enth day, tmless the pulse remauis strong and full. He 
does not believe in giving quinine in small and repeated 
doses during the active stages. When the temperature 
is 104° or over he gives 50 grains of sulphate of quinine 
and follows the same course as given above. When the 
temperatxire is 103° he gives from 30 to 40 grains, and fol- 
lows the same course. During convalescence he has found 
iron, quinine, strychnine, guaiacol, and cod-liver oil of 
value. What has served him best are thorough ventila- 
tion and sunlight, with plenty of milk, eggs, and beefsteak. 

The Yellow Fever Epidemic of 1903 at Laredo, Tex. — 
G. M. Guiteras reviews his experience in this epidemic, and 
draws the conclusions that the results obtained through 
the efforts to combat the epidemic at Laredo demonstrate 
that the Stegomyia jasciata is the only means of trans- 
mitting the disease. Oiling all water containers and 
deposits of stagnant water was completely successful 
in preventing the reproduction of mosquitos. Inasmuch 
as the Stegomyia jasciata can become infected by 
biting the patient during the first three days of the dis- 
ease only, it is of vital importance that cases of fever 
be reported at the earliest possible moment, so that they 
may be screened. It is impossible to obtain good results 
without a mosquito-proof yellow-fever hospital. The 
difBculties of handling an epidemic are increased when 
such outbreak occurs on the frontier. Arrangements 
should, therefore, be entered into by treaty with con- 
tiguous foreign countries, so that sanitary measures may 
be carried out jointly by the countries interested. Those 
residing within the sphere of influence of the Stegomyia 
jasciata should be taught through the medium of the public 
press to protect themselves against yellow fever by de- 
stroying the means for the propagation of the mosquito 
and by protecting themselves against the mosquito by 
efficient screening. If the first case presenting the 
slightest suspicious symptoms of that disease were 
promptly made public, and the proper modem precau- 
tions taken, there would be no danger of the disease 
eoreading. 

The Medical News, July g, 1904. 

Yohimbine; Its Use in the Treatment .'of Eye, Ear, Nose, 
and Throat Diseases. — J. H. Claiborne and Edward B. Co- 
burn have tested the local anaesthetic properties of yohim- 
bine. They regard it as inferior to cocaine in all operations 
upon the eye on account of the congestion produced by it. 
For the examination of the nose it was not as effective as 
cocaine, because the contraction caused by it was not so 
marked. It has been found useful in ear and nose work. 
Its advantages may be summed up as follows: It is non- 
toxic; there is long duration of anaesthesia after its use; it 
does not markedly contract the tissues; the taste is only 
slightly bitter; it does not cause unpleasant contraction 
of the throat and mouth. Its disadvantages are that it 
does not keep well: it does not contract the tissues; after 
its use there are hypereemia and hemorrhage after opera- 
tion; salivation is caused by its use. 

The Theory of Mutation in Its Relation to Medicine. — ■ 
Jonathan Wright declares that evolutionary science is 



drifting in the direction of spontaneous generation. He 
believes that the theory of mutation in biology, if it is 
settled in the affirmative, will have a very important 
bearing upon our knowledge of the etiology of disease. 
The author recalls the declarations of De Vries, an Amster- 
dam naturalist, that there are certain jumps in the life 
history of species, which are really the origin of species. 
He has specially studied the primrose in this regard, and 
has observed changes which he calls mutations, and these 
changes were so sudden and profound that he has come 
to believe that all species at some time in their life history 
exhibit an excessive instability from which new and dis- 
tinct forms arise. The writer' does not see how this idea 
in any way upsets the fundamental idea of Darwin. He 
believes that "the theory of mutation" is important to 
the conception of microbic disease. In the decades pre- 
ceding the middle of the last century, it was the common 
belief that from time to time the character of certain dis- 
eases changed in their clinical manifestations; that, for 
example, during a longer or shorter time, pneumonia pre- 
sented sthenic types, suitable for bleeding, followed by 
asthenic types when such procedures were disastrous. 
Again, diphtheria is not sufficient to account for the 
severity of the cases of throat inflammation with which 
Hippocrates had to do. In the history of smallpox and 
phthisis we know with what rapidity early races have 
been all but exterminated by these diseases. Ancient 
books give no record of many a scourge which has since 
worked havoc among civilized nations. The writer sug- 
gests that we may suppose that many diseases as the re- 
sultants of primordial changes in the cell and the micro- 
phyte entered in the dark ages upon a period of mutability 
similar to the primrose in Holland after it was carried 
there from America in 16 13. In the pre-Renaissance, 
diseases seem to have originated with a shock or jvimp, 
since that time being more or less constant except for 
the minor changes in type. Just as with plants, they 
may have been formed from a mother disease which may 
still exist. It is in the period of upward of 1000 years 
after the fall of ancient Rome that we seek the origin of 
smallpox, scarlet fever, measles, whooping-cough, influenza, 
possibly even syphilis. The newer the disease, the more 
limited' its range among animals. Phthisis and pneu- 
monia are coeval with the dawning of the history of man ; 
diphtheria can be traced back to the Babylonian Jews. 
Reports of the influenza were the first to emerge from 
the obscurities of the dark ages. These diseases are 
widespread in the animal world, but syphilis, srnallpox, 
whooping-cough, scarlet fever, measles, of later historical 
mention, are also markedly less widespread in the animal 
kingdom. As to spontaneous generation, the writer does 
not'believe that the phenomena, both biological and his- 
torical, of microbic disease necessitates its assumption, and 
we have little ground for this theory in facts hitherto 
presented. He believes that whatever may be the trend 
toward this view, the labors of Lowenhoeck, Spallanzanni, 
Virchow, Tyndall, and Pasteur, have definitely thrown 
the burden of proof on its future advocates. 

American Me dicitte, July 9, 1904. 

Gangrene of the Finger Caused by CarbolicTAcid. — 

George Erety Shoemaker believes that not enough atten- 
tion has been given to the danger of producing gangrene 
by the use of even comparatively weak solutions of car- 
bolic acid applied as a dressing for a number of hours. It 
has been proved that the use of full strength of the acid 
is not necessary to produce gangrene. In using dilute 
solutions on a finger, it seems to be necessary for the 
production of gangrene that the entire finger be sur- 
rounded bv the solution and be tied up in it for not less 
than 24 hours. The literature furnishes a number of 
such cases. In most cases the eft'ect is painlessly pro- 
duced bv a dressing kept moist for about 24 hours, and the 
strength of the solution employed may be from i per cent, 
to 5 per cent. The result is not due to tight bandaging; 
the' dilute solution is capable of producing the effect, and 
gangrene does not always follow the application. It has 
been shown experiment'ally that the death of the part is 
due to chemical action and that other diluted chemicals 
may produce the same effect if applied by a moist com- 
pre'ss for 20 to 24 hours. The same solution does not 
always produce the same result. Caution in regarS to 
this "matter is especially necessary in dermatology and 
in minor surgery. 

Concerning the Invasion Period of the Malignant Esti- 
voautumnal Tertian Malarial Parasite. — Thomas W. Jack- 
son states that it seems not at all imlikely, as contended 
by a number of observers, that the period of incubation 
of malarial fevers is a variable one, and that the variation 
is an extreme one, depending upon certain ill-understood 
conditions of the subject of inoculation, and the stage and 
variety of the inoculated parasite. The writer reports 
eighteen cases, however, which seem to support the propo- 



io8 



MEDICAL RECORD. 



[July 1 6, 1904 



sition that, under the same conditions, the period of incu- 
bation for a number of individuals inoculated by mosqui- 
tos with the same malarial parasites, at approximately 
the same time, varied but slightly. After a careful study 
of these cases, the writer feels justified in stating that: 
In an epidemic of eighteen cases of estivoautumnal 
fever (of the malignant variety) which occurred in Troop 
A, Sixth U. S. Cavalry, in the Philippine Islands in April, 
1902, the invasion or incubation period was between ten 
and eleven days. The author believes that the inoculat- 
ing mosquitos in this epidemic obtained the malarial para- 
sites probably from native Filipinos who had previously 
been in the vicinity, it being a fact well known and proven 
that the natives suffer extensively from malarial disease, 
in both its active and latent forms. 

The Treatment of Gallstones Found as a Coincidence in 
Abdominal or Pelvic Operations. — John G. Clark presents 
the following conclusions: (i) The usual statement 
that 95 per cent, of gallstones produce no symptoms is 
fallacious because it is drawn from an autopsy and 
dissecting-room statistics. (2) Recent researches .point 
very strongly to the bacteriological origin of gall- 
stones. (3) Bile is not bactericidal, for in the ma- 
jority of cases of cholelithiasis microorganism of a more 
or less pathogenic nature are discovered. (4) Under 
these circumstances, many more or less vague symptoms 
attributed to gastrointestinal or general constitutional 
disturbances may arise from to.xins elaborated around 
these foreign bodies in the gall-bladder. (5) All clin- 
icians admit that there is a wider hiatus in the clinical 
symptoms between the early formation of gallstones and 
the so-called classic attacks of biliary colic with jaundice. 
(6) Abdominal surgeons should make a most careful 
record of all gastrointestinal or hepatic symptoms and 
other v'ague epigastric pains and associate these with an 
examination of the gall-bladder with a view to estab- 
lishing a further link in the symptomatology of chole- 
lithiasis. (7) As cholelithotomy in a large series of 
cases has been attended with less than 2 per cent, 
mortality, the coincident removal of gallstones with 
some other abdominal operation is not a hazardous 
undertaking. (8) In the author' s cases, more than 50 
per cent, have shown symptoms which could be un- 
questionably or with great assurance attributed to the 
presence of gallstones. (9) This coincident operation 
should be dictated by the most careful judgment, for 
if the patient is in a critical condition from a prolonged 
operation, or the primary operation has been a septic 
one, this extra operation may be attended by serious 
results. 

Xew York Medical Journal, July 9, 1904. 

The Home Treatment of Pulmonary Tuberculosis. — ■ 

E. Fletcher Ingals says that in at least two-thirds of the 
cases of pulmonary tuberculosis recovery ensues, for 
statistics showed that only 12 per cent, die of this dis- 
ease, and autopsies showed that in 25 per cent, recovery' 
froni it had taken place. He believed the so-called anii- 
septic treatment was often beneficial, the open-air treat- 
ment equally so, and forced feeding was more important 
than either, while tonics, digestive agents, and anodynes 
that did not interfere -n-ith the ordinary functions of the 
body were also of much importance All of these should 
be combined and the patient placed in a good climate; 
when the latter was impossible much could be done at 
home. He then reported a case in which open air living 
could not be secured, and which illustrated the eflfects 
of home treatment, \rith as liberal feeding as possible, 
aided by tonics and digestive agents, anodynes to pre- 
vent excessive cough, and antiseptics in large doses. A 
second case was cited to illustrate the benefits of the open- 
air treatment. 

Effects of the Dry Carbonic Acid Gas Bath on the Cir- 
culation and on the Diseased Heart. — Achilles Ro.se gives 
a description of his bathtub, and since he could not 
find in the literature a record of the effects of the dry 
carbonic acid gas bath on the number of pulsations, 
one was presented from his case book. The rapidity of 
the whole blood circulation in the superficial vessels 
increases during the bath, and this was sho^\Ti bvthe in- 
creased strength and volume of the radial pulse. The 
pulse of the bather, within a few minutes after having 
entered the bath, resembles a pulse stimulated by alcohol. 

The Unhealthfulness of Noise.— J. A. Guthrie. U. S. 
N., asks what objections could be made against the state- 
ment that noises create a disturbance of the nervous 
elements to such degree that they should be given a place 
in the category of disease causations ? When a healthful 
condition of the nerve exists, we bear a greater amount 
of nt-rvous shock \\-ith impunity; but by frequent repe- 
titions of this shock, we are rendered less able to with- 
stand the resulting jar. The author instances certain 
facts to prove that sudden noise is disconcerting. 



The Lancet. July 2, 1904. 

The Treatment of Hemorrhoids and Allied Conditions 
by Oscillatory Currents of High Tension. — T. J. Bokenham 
bases his experience on 1 18 cases. It seems to be admitted 
generally by all who have put matters to the testt hat (i) 
Doumer's method is striking and quickly successful in 
cases of sphincter fissure and in healing the small fissures 
so often associated ^ith hemorrhoids; (2) it is valuable 
in relieving pruritus ani associated ^-ith similar conditions; 
(3) its value in the treatment of external and internal 
piles is greatest in early cases which do not exhibit ex- 
cessive hj'perplasia and thickening of the tissues ; (4) in 
cases of very old standing accompanied by much hyper- 
trophic change and infiltration of the hemorrhoidal tissues 
the treatment gives poorer results, and at best has to be 
persevered in for long periods. 

Accidental Vaccina of the Nasal Cavity. — W.H. Bowen 
reports such a case occurring in a woman who was nursing 
her baby, who had been successfully vaccinated. The 
mother had not been vaccinated since she was a baby 
Anyone who has watched a baby, either taking the breast 
or being carried in the mother's lap, remembering the 
restless way in which babies "claw" at everything about, 
and with special frequency the mother's face, ■will readily 
imderstand the ease with which inoculation was brought 
about Of forty-six other cases of accidental vaccination 
which the author has found reported, thirty-one were on 
the face, one on the tongue, eight on the trunk, and fotir 
on the limbs. The only other case of accidental vaccina- 
tion of the nasal cavity was reported in the Birmingham 
^ledicat Refiew {or 1903. 

Use of Sodium Arseniate Hypodermically in Tsetse-fly 
Disease in Cattle. — Edward J Moore says that some 
months ago the Government of Southern Nigeria estab- 
i shed an experimental farm with the intention of teach- 
ing natives to use cow's milk as an article of diet for their 
children and thereby to put a natural check on twin mur- 
der by removing the reason on which the practice is based, 
viz., the inability of most ill-fed women to rear two chil- 
dren. Twenty-two cattle, principally West Indian, were 
established there and, after one month, began to show the 
first signs of the disease. Fowler's solution of arsenic was 
administered in one-drachm doses three times daily with- 
out improvement. Larger doses of one ounce were at- 
tempted, but had to be discontinued because they in- 
creased the already existing tenderness of the mouth to 
such an extent that the animals refused to take food and 
their general symptoms became aggravated. Under 
these circumstances he prepared a one-per-cent. solution 
of sodium arseniate, rendered slightly alkaline, and select- 
ing the worse case injected one ounce of this hypodermi- 
cally on two occasions at an inter\'al of one week. The 
beneficial effect was marked and immediate. 

Non-flagellate Typhoid Bacilli. — J. W. W. Stephens' 
method for staining nagclla with silver was a modification 
and simplification of van Ermengem's method, and he had 
constantly got positive results with it, so that he felt 
secure in describing it last year. Shortly after having 
done so he was surprised at being \mable to stain flagella 
in a culture of typhoid bacilli which he had used for demon- 
strating the method. Further experimenting made him 
feel justified in concluding that his failure to stain the old 
cultures was due to the fact that there was no flagella 
there to stain. He therefore concluded that we may 
have non-flagella tj'phoid bacilli. The bearings of this 
observation may be of interest, (i) It may be necessary 
to pass a bacillus, e.g. Bacillus dj'senteriae (Shiga), 
through an animal or to examine freshh' isolated bacilli 
before we can be quite certain that they do not norinally 
possess flagella. (2) The typhoid bacilli which were ex- 
amined above, and which he believed did not possess fla- 
gella, were said to "react normally " in tj-phoid agglutina- 
tion tests. If this was so then flagella could not be an 
essential factor in this phenomenon. 

British Medical Journal. July 2. 1904. 

Pneumococcal Appendicitis and Peritonitis. — Lauriston 
Shaw and Herbert French describe the case of a girl 
aged eighteen years who, when she was admitted to the 
hospital, was too ill to operate on. She died a few hours 
after admission. Autopsy seemed to disclose the con- 
dition of primary acute appendicitis with general peri- 
tonitis Cultures taken from the appendix and from 
the peritoneal lymph yielded an almost pure growth of 
pneumococci. The case is apparently one of primary 
pneumococcal appendicitis, associated with pneumo- 
coccal peritonitis, and the authors think it worth re- 
cording. 

The Leishman-Donovan Body in Ulcerated Surfaces. — 

Patrick Manson and George C. Low report that in the 
infiltrated areas of 3 small intestinal ulcer, and in an 
ulcer from the large intestine. Leishman-Donovan bodies, 
few in number but unmistakable, have been found. 



July 1 6, 1904] 



MEDICAL RECORD. 



109 



They were inclosed in cells. In sections of liver, spleen, 
and lymphatic glands the position of those bodies is 
doubtless, in the majority of instances, intracellular. 
The writers have never seen the parasites in the red 
blood corpuscles in sections or otherwise. Wright and 
James have foimd these bodies on a similar organism, 
m ulcers of the integuments (Oriental sore), Christophers 
in intestinal ulcers. The writers ask if failing the dis- 
covery of any other means of exit from the body, may 
it not be that the normal route of escape from the para- 
site is by an ulcerated surface? It is seen from these 
observations that these parasites may escape by the in- 
testinal canal. 

Intravesical Separation of the Urine from Each Kid- 
ney. — B. G. A. Moynihan speaks of two methods of ob- 
taining the urines from each kidney separately — by 
catheterizing the ureters, thus obtaining the urine be- 
fore it has entered the bladder, or by creating a septum 
in the middle of the bladder in such a way that the 
urine from each ureter is confined to its own side of the 
bladder frona which it is drawn through a small catheter. 
For the last method, the first perfectly efficient instru- 
ment was made after some modifications of the original 
pattern by Luys of Paris. It is made so that a thin 
india rubber sheathing is raised up, forming a septum. The 
lateral pieces, fitting on to the sides of the central piece, 
consist of two catheters having several eyes. Each 
catheter drains its own side of the bladder after the sep- 
tum has been created. Another perfectly satisfactory 
instrument is that of CatheHn of Paris. This has a leaf 
or septum of india rtibber. This instrument presents 
no difficulty in the introduction, but if the bladder is 
small and the septum is pushed fully into the bladder 
it will twist to one side, and the partition will be defective. 
Luys' instrument is of no value unless the bladder be 
fairly normal in size and position. The writer is at 
present in favor of the use of Luys' instrunient for the 
female, and of CatheUn's for the male, though he adds 
that a more extended experience may modify his opinion. 

Pads upon the Finger Joints and Their Clinical Rela- 
tionships. — .Vrchibald E. Garrod defines these pads on 
nodules as excrescences, which are almost confined to 
the dorsal aspects of the interphalangeal joints of the 
proximal row, and are only very rarely seen upon the 
terminal joints of the fingers. There is no striking sym- 
metry in their distribution. They vary in size from 
that of split peas to that of the halves of hazel nuts. 
They are usually central in position, though they may 
incline to one or other side of the joint. Sometimes the 
lumps are quite painless, but more often pain is com- 
plained of. especially when the fingers are fle.xed. They 
are doubtless mainly composed of fibrous tissue. There 
does not appear to be any connection between these 
pads, and any of the morbid conditions which are usually 
grouped together under the names of rheumatoid or 
osteoarthritis. Two elderly patients, however, did have 
well-marked Heberden's nodes in addition to the pads. 
There is doubtless an intimate connection between 
Dupuytren's contraction and these pads. At least six 
out of twelve patients showed Dupuytren's contraction. 
This might be styled a paragouty lesion. But the con- 
nection of these pads with gout is clearl}' less obvious 
than that with Dupuytren's contraction. The writer 
knows of no plan of treatment which is of any avail in 
reducing the size of the pads. A patient who develops 
them in early life appears to be liable finally to develop 
Dupuytren's contraction of the palmar fascid. but aside 
from this they do not seem to possess any grave prog- 
nostic significance. 

Deutsche mcdizinische Wochcnschrijt, June 23, 1904. 

Scapular Crepitus. — Axmann describes an instance of 
this rare condition in a boy of eighteen, in whom a crep- 
itus gradually developed under the right shoulder-blade. 
Otherwise the patient was normal and in good health. 
On lifting the shoulder the crackling sound could be heard 
at a distance of several yards. Passive motion fails to 
elicit the noise and muscular action seems to be requisite. 
A Rontgen ray picture failed to show any abnormalities. 
As the patient displayed no symptoms requiring allevia- 
tion, no treatment was instituted. Kuttner, in his report 
of twenty-two cases thus far noted, calls attention to the 
following etiological factors: bony deformities in the 
scapula or thorax, the result of tuberculosis or syphilis 
ankylosis in the shoulder-joint; paralysis with muscular 
atrophy; abnormal synovial diverticulse. None of these 
could be demonstrated in this particular patient. 

A Case of Senile Dementia Accompanied by Contracted 
Kidneys. — G. Lomer reports a case in .a man of fifty-six 
in whom these two conditions were closely associated 
and probably dated from the same cause — the presence 
of an arteriosclerosis. The differential diagnosis was a 
difficult matter, for during the entire period of observa- 



tion, no specific ura;mic symptoms, such as vomiting and 
convulsions, ever appeared. The urine showed a high 
specific gravity and the amount of albumin by Esbach's 
test, was 13 per cent. An albuminuric retinitis was not 
present at any time. The arteriosclerosis could be ac- 
counted for by a history of both alcoholism and syphilis, 
and there was also a possibility that an attack of menin- 
gitis at the age of thirty may have weakened the cerebral 
vessels. A noteworthy point in this case was the early 
appearance of the dementia, which is usually not observed 
until about sixty-five. The patient was favorably influ- 
enced by sanatorium treatment, and in a few months the 
albumin dropped from 13 per cent, to 2.5 per cent. The 
psychical disturbances were also improved. The prog- 
nosis is very uncertain, however, as to the original disease; 
the arteriosclerosis will resist all efforts at a cure. 

Berliner klinisclie Wocliensekrifl, June 20, 1904. 

Destruction of the Ear Drum by Lightning. — K. Burk- 
ner calls attention to the rarity of injuries to the auditory 
apparatus by lightning, of which only a few cases have 
been reported. The author's patient was a boy of eigh- 
teen, who was in a tower which was struck by lightning. 
An aural examination showed an extensive tear in the 
membrane, part of which was folded back over the handle 
of the malleus. That the perforation did not occur as 
the result of a fall, to which the boy was also subjected, 
is shown by its contour, the slight amount of hemorrhage, 
the absence of symptoms in the labyrinth, and the fact 
that the only other injuries on the head were the bums 
caused by the flash. It remains an undecided question, 
however, whether the laceration was due directly to the 
electric spark or to the shock accompanying the sudden 
electrical discharge from the body. 

The Value of Water in Disease. — E. Homberger dis- 
cusses the importance of a plentiful administration of 
water in disease processes, especially those accoinpanied. 
By this method the most distant cells may be reached 
and restored to their normal physiological condition. 
As the conception of a cellular pathology also requires 
a cellular therapy, this agent seems to be the most ra- 
tional means to attain the end. During the course of a 
fever, there is an insufficient quantity of water present 
in the system, and this the body is slow in giving up, re- 
.sulting in a diminished quantity of sweat and urine. 
Perspiration, the author claims, is only restored when the 
temperature of the body begins to drop and the super- 
fliious water is no longer needed. This is contrary to the 
usually accepted opinion. Although water is by no 
means a panacea, it is of great value in all those diseases 
in which the toxins have circulated in the blood for a con- 
siderable period of time. But when these rapidly leave 
the circulatory system and unite with the cells, this agent 
is of little avail. 

M nnchener mcdizinische Wochcnschrijt. June 21, 1904. 

Herpes Zoster in Croupous Pneumonia. — Riehl observed, 
among 481 cases of croupous pneumonia, that a well- 
localized herpes zoster developed in 129 — about 27 per 
cent. This, however, is considerably less than the number 
stated by other authors, who report about 40 per cent. 
The affection seems to afflict the male sex more often than 
the female, and usually appears on the third or fourth 
day of the disease. The author calls particular attention 
to the localization of the eruption, which is most marked 
over the distribution of the second and third branches of 
the trigeminus, and especially the infraorbital nerve. 
It is rarely found in the area of the first branch, and only 
on the neck, trunk, or extremities in exceptional instances. 
Pneumonias in children and the aged usually run their 
course without any herpes eruption. Mild cases of pneu- 
monia are characterized by an extensive eruption, while 
the severest cases are most always free from this compli- 
cation. 

Orthodiagraphy and Percussion of the Heart. — Schule 
has studied, for purposes of comparison, these two methods 
for mapping out the boundaries of the heart. The former, 
in which the determination is made by means of the a:-rays, 
was introduced by de la Camp and Moritz, and has 
also been used by a number of other observers, all of 
whom are in agreement as to the results obtained. The 
authors find that the cardiac area as mapped out by the 
ordinary methods of percussion does not exhibit any 
appreciable variations from that determined by the use 
of the .r-ravs. Percussion need not be superseded by the 
rays, but m doubtful cases the ideal procedure would 
consist in a verification of the results obtained by per- 
cussion, by an examination with the *-rays. The latter 
is undoubtedly a most efficient secondary diagnostic aid. 

An Unusual Injury to the Orbit. — F. Salzer reports an 
interesting case in which a bit of leather whip lash about 
i>2 cm. long remained imbedded in the orbital cavity 
for a period of three weeks without being discovered. 
The man had been struck in the upper lid, which pre- 



no 



MEDICAL RECORD. 



Utdy 1 6, 1904 



sented a small wound. The eye was much contused but 
the wound healed promptly. Suppuration followed later 
on, but the probe failed to detect any foreign body in the 
discharging sinus until about a week afterward, the very 
much softened fragment of leather was extracted from 
the wound. The author accounts for its entrance by the 
fact that on the day the injury occurred, the weather was 
very cold and the leather was frozen stiff and probably 
covered with ice, which faciliated its entrance into the 
orbit. The patient made a good recovery. 

The Relation of the Weutrophile Leucocytes in Infectious 
Diseases.^J. Arneth claims, as a result of extended inves- 
tigations, that the progress of the disease process may be 
rendered demonstrable to the eye by the morphological 
changes in the neutrophile leucocytes. To some extent 
each type of infectious disease was associated with definite 
changes — in one type they were well marked, in another 
less so, and in a third, scarcely noticeable. The same 
author now presents some further types which he has 
studied, including cases of miliary tuberculosis, traumatic 
tetanus, varicella, meningitis, diffuse peritonitis, pur- 
pura, sepsis, typhoid pneumonia, hepatic abscess, and 
hydrochloric acid poisoning. The neutrophile leucocytes 
are divided into five classes, according to the division of 
the nucleus into one, two, three, four, five, or more parts. 
In the case of miliary tuberculosis, which ended fatally, 
almost all the cells belonged to classes one and two. This 
he interprets as meaning that the body is only supplied 
with only the younger and immature elements for its pro- 
tection. The older classes, containing a more divided 
■nucleus, being practically wiped out. This picture grew 
increasingly worse toward the end. Very few morpho- 
logical changes were noted in the leucocytes from the 
case of tetanus, the only difference noted being the in- 
creased percentage of neutrophiles in proportion to the 
total number of leucocytes. In a case of smallpox which 
recovered, the maximum change was noted in the begin- 
ning, and as the patient got better, a gradual return to 
the normal took place. The two cases of suppurative 
meningitis presented an anisohypercytosis, and changes 
in the neutrophiles were very limited. The remaining 
cases also showed characteristic changes, and the author 
hopes to have his findings substantiated by other ob- 
servers. 

French and Italian Journals. 
Continued Slow Pulse; Osseous or Calcareous Degener- 
ation of the Myocardium. — M. H. Dufour observed a 
patient whose pulse was from 36 to 40 a minute. Autopsy 
revealed a calcareous or osseous degeneration of the 
myocardium, remarkable for its extent. It involved the 
mitral valve and formed a tumor the size of a nut, which 
was encysted by a zone of tissue which appeared to be 
■fibrous. There were several superficial areas of softening 
in the brain, which accounted for the attacks of apoplexy 
from which the patient had suffered. Examination of the 
bulb and pncumogastrics was negative. — Le Bulletin 
Medical, June 11, 1004. 

Considerations of 640 Cases of the Widal Reaction. — 
E. Cler. C. Quadrone, and A. Ferazzi have recorded 640 
cases in which the Widal reaction was found in the labo- 
ratories and hospitals of Florence in 1902-03. They 
found the reaction of agglutination in various non- 
typhoid febrile diseases, but not in a less dilution than 
1-20. They also found it in some non-febrile affections. 
In 166 casesof true typhoid they found the Widal reaction 
present. They conclude as follows: (i) Serum of per- 
sons not having typhoid may produce agglutination like 
that of Eberth's bacillus. (2) This action if observed 
in a high grade of dilution, less than 1-20, may be ascribed 
to the presence of the Kberth liacillus in a latent or pre- 
typhoid infection. (3) In a dihition greater than 1-20 
it has a diagnostic value for tyi)hoid. Absence of this 
reaction does not exclude typhoid, and is du,e to the 
formatios in the blood of anti-agglutinins. — Rivista 
Critica di Clinica Mcdica. May 14, 1904. 

Congenital Cyanosis. — Mdry states that the congenita^ 
cardiac lesion which occasions the cyanosis consists of two 
principal lesions: Stenosis of the pulmonary artery; 
mterventricular communication or Roger's sickness. 
The writer describes three cases which he has lately 
observed, all of which showed the same general symptoms. 
When the child cries, a crisis of paroxysmal cyanosis is 
precipitated. These crises occur two or three times a day, 
lasting from five to ten minutes, accompanied by acute 
dyspncea and convulsions. Auscultation showed a pro- 
longed systolic muniiur in the middle cardiac region. In 
one case the extremities were always cold. Sometimes the 
axillary temperatiue drops from 2 to 3 degrees. The 
blood corpuscles are greatly increased in number. The 
liver and spleen are not increased in volume. The 
prognosis in these cases is very bad. The children are 
carried ofl by their cardiac troubles or by pulmonary 
tuberculosis. Treatment should consist chieHv in observ- 



ing for these little patients the general laws of hygiene. 
They should be guarded from all emotion. — Journal des 
Praticiens, June 11, 1904. 

Contribution to the Pathology of Tabes Dorsalis — 
Carlo Fantiggia states that most modem authors regard 
progressive paralysis and tabes dorsalis as the result of 
the same pathological process taking place in different 
anatomical regions, in the cortex of the frontal lobes of 
the brain in paralysis, in the spinal cord in tabes. Or 
we may have a mixed form, involving both parts and 
giving symptoms of each disease. Many consider these 
diseases as a toxic effect of syphilis, yet independent of 
syphilis itself. Mercimals do not give good results in 
tabes, and in some cases give distinctly bad ones. These 
diseases may be the i^esult of poisons produced in the 
system, resulting from the same cause as syphilis, yet 
which are not affected by mercury, as the late paralysis 
of diphtheria, is not improved by antitoxin. Such 
poisons may be elaborated by other diseases than syphilis. 
The author cites a typical case of tabes dorsalis with apo- 
plectiform attacks.— <?az2eHa Medica Lombarda, Ma)' 23 , 
1904. 

Biological Action of the Sedative Application of the 
Positive Pole as Produced by the Different Apparatus 
Used for Producing the Continuous Current. — Giorlama 
Mirla considers the stabile application of the anode 
over the seat of pain as of great value in treating painful 
affections of the ner\'es and parjesthesia^. The failures 
in this method are due to the source from which the 
electricity used is derived. The current must be pei"- 
fectly even, because the slightest oscillations and varia- 
tions in strength stimulate the ner\'e treated. The 
application must begin gradually, with a very slowly 
increased current, and must cease in the same w'ay. 
The effects are different according as the current is de- 
rived from a source whose voltage is small, or one whose 
voltage is great, but reduced by the interposition of 
great resistance. If the electric light current is used 
there may be \arious sources of the current, and they 
may vary at different times of day. When produced 
by a dynamo, the current has slight oscillations and vari- 
ations that, although not detected by measuring instru- 
ments, are still felt by the more delicate nerves of the 
human body. The author uses only the Leclanch^ cell, 
or those of Ringer. — Giornale d' Etettricitii Medica, May 
and June, 1904. 

The Functions of the Kidney and Renal Insufficiency. — 
Cauterman, after considering this subject from vaiious 
points of view, speaks of the treatment of renal insuffi- 
ciency. He states that the exact treatment of this af- 
fection is based upon an intimate knowledge of the 
phenomena of this condition. The indications are va- 
rious. One should avoid introducing into the organism. 
in the form of food and drink, substances with a high 
molecular concentration, rich in toxins, rich in chlorides. 
Fermentation and abnormal alterations of food ing^ested 
should also be avoided, for a food, harmless in itself, 
can become irritating and injurious, under certain con- 
ditions, sitch as stagnation, etc. The compensatory 
organs of the kidney should be carefully watched — the 
liver the intestine," and the skin. The drugs recom- 
mended for this condition should be carefully studied. 
And all of the mechanical means known for diminishing 
the tension of fluids in Bright's disease should be con- 
sidered. — Annales de la Sociiti Midico-Chirurgicale 
d'Anvcrs, March-April, 1904. 

Radiotheraphy in the Treatment of Tumors of the 

Stomach. —Doumer and Lemoine have treated twenty 
gastric tumors by tliis method. Of these they believe 
that three cases were completely and finally cured. A 
fotirth is on the way to recovery, while a fifth in whom 
the improvement was ver>- rapid, and in whom the tumor 
completely disappeared, has had a relapse that does 
not )-ield to treatment. In the other cases the tumor 
has had a variable course according to the case. In all 
of the cases without exception this treatment has caused 
the disappearance of, or great diminution of, pain, and 
this from the first application. Vomiting has ceased 
or has greatly diminished, and feeding has thus become 
much easier. Without any doubt the general state has 
been greath' improved. Doumer and Lemoine conclude 
that there are certain forms of gastric tiunors in which 
this treatment has worked a complete cure, lasting so 
far for a year and a half in several cases, and other forms 
. in which the treatment has been incomplete in its effects, 
destroying the tumor in its original place, but not hinder- 
ing its extension to neighboring parts and its metastases 
to distant p.arts. — Le Bulletin Judical. June 15, 1904. 

Extirpation of Cancer of the Kidney. — M. A. Malherbe 
described this case which came imder his observation. 
The patient, a man of forty-six years, was suffering from 
hematuria in September of 1903. From that time he 



July 1 6, 1904] 



MEDICAL RECORD. 



Ill 



lost considerable flesh; he was yellow, and had a cachec- 
tic look The urine seemed normal, and was very abim- 
dant. On palpating the right flank, a tumor was clearly 
felt. It reached down to the iliac fossa, and was quite 
movable. In spite of the cachexia of the patient, as 
he had nothing to lose and everything to gain, Malherbe 
decided to operate on February 13, 1904. There was 
little hemorrhage, but an injection of artificial serum 
was given. The affected kidney weighed 390 grams. 
The two poles were comparatively healthy, but on the 
posterior surface at about the union of the lower and 
middle thirds, was a large tumor. On section the cor- 
tical substance looked almost as much like tuberculosis 
as it did like a new growth. But in the pelvis the new 
growth was very evident. Histological examination 
showed the tumor to be alveolar epithelioma or cancer 
of the kidney. At the beginning of March the patient 
began to improve slightly, but still had a cachectic 
aspect. Finally, in April, the improvement was decided 
He ate very well, and increased in weight. About April 
20 he left the hospital in a very satisfactory condition. — 
La Medecinc Modcrne, June 15, 1904. 

Peroxide of Magnesium in the Treatment of Acid Diar- 
rhoea of Adults. — Betherand and Rene Galtier declare 
that the acid diarrhoeas seem to them to be the only 
type that indicate treatment by means of peroxide of 
magnesium. Peroxide of magnesium is decomposed 
only in an acidi medium. In the stomach, hydrochloric 
acid or the fermentation acids decompose the peroxide 
into chloride of magnesia and hydrogen peroxide, and 
the latter is finally separated into water and oxygen. 
The drug is administered in the form of keratinized pills 
so that the specific action of the drug may play its r61e 
in the intestmes. The faeces in the normal state and 
under the influence of a mixed diet are alkaline or neutral, 
but they become acid under the influence of a considerable 
gastric acidity, which the secretions of the intestinal 
glands, of the Hvcr and of the pancreas are unable to 
offset. It is in such cases that the peroxide of magnesium 
has given the best results. The writers then relate the 
histories of several cases which corroborate the opinion 
of Robin that there is in this drug an antiseptic as well 
as antidiarrhoeic power, most important, when the 
origin of this diarrhoea is fermentation. It is only when 
the contents of the intestine are acid that the magfnesium 
peroxide decomposes and sets free its oxygen. — Bulletin 
General de Th^rapeuHque, June 15, 1904. 

The American Journal of the Medical Sciences, June, 1904. 

Mental Symptoms Associated with Pernicious Anaemia. 
— William Pickett states that a composite picture of the 
mental disturbance in these cases presents a shallow confu- 
sion with impairment of the ideas of time and place (disori- 
entation), more marked on awakening from sleep. The 
patient fabricates, relating imaginary experiences of "yes- 
terday " in a circumstantial way. Illusions, particularly 
of identity, are common. Hallucinations appear at times, 
pertaining to any of the senses. Based upon these, per- 
secutory delusions arise which are usually transient. 
Thej' may persist for considerable periods and be thus, 
somewhat fixed. They may be even systematized. This 
psychosis is mainly an abeyance of mind. It rarely 
presents the spontaneous excitement by which some 
types of confusion seem to merge into true mania. The 
term amentia seems appropriate for it. Korsakoff's 
disease and folic Brightique resemble it closely. 

The Relation of Cells with Eosinophile Granulation to 
Bacterial Infection. — Eugene L. Opie concludes that cer- 
tain bacteria (bacillus tuberculosis, bacillus cholera; suis), 
producing somewhat chronic, fatal infection in guinea- 
pigs, cause the eosinophile leucocytes gradually to dis- 
appear from the circulating blood. The study of dead 
tissues gives little indication of the behavior of the eosino- 
phile leucocytes during the course of bacterial infections. 
After the inoculation of an organism producing an infec- 
tion from which the animal is capable of recovering, 
eosinophile leucocytes disappear from the peripheral 
<;irculation. to a proportion of less than 190. The number 
then increases for a few days, after which it again becomes 
normal. When bacteria are introduced into the peri- 
toneal cavity of the guinea-pig, the large mononuclear 
and eosinophile cells contained in the peritoneal fluid, 
form compact clumps, which adhere in great part to the 
surface of the omentum, so that for a time eosinophile 
cells have almost completely disappeared from this fluid. 
After about an hour they again appear. Eosinophile 
cells, rarely if ever, act as phagocytes, ingesting bacteria. 
Eosinophile leucocytes are ingested by large mononuclear 
cells (inacrophages). In cases of severe bacterial ' in- 
fection, eosinophile myelocytes accumulate in the spleen 
and may be found in the circulating blood, within from 
two tc four hours after inoculation, showing that these 
elements are derived from the bone-marrow and are not 
found in the spleen. Bacteria exert a chemotactic in- 



fluence upon cells with eosinophile granulation, attract- 
ing them from the bone-marrow into the blood, and from 
the circulating blood to the site of inoculation. 

Traumatic Intestinal Rupture, with Special Reference 
to Indirect Applied Force. — Emanuel J. Senn calls atten- 
tion to internal injuries with no manifest external lesions. 
These injuries are most frequent in men and young 
adults, on account of their greater exposure to injury. 
Generally speaking, blows above the level of the umbilicus 
are unlikely to cause intestinal injuries. Pathologically 
the injuries may be classified as (i) contusions; (2) rup- 
ture; incomplete, complete. Contusions may be of all 
degrees. Incomplete ruptures, when one or two of the 
tunics are torn, in all probability are frequent; however, 
according to pathological investigation, they are con- 
sidered rare. Complete ruptures, when all the tunics 
are ruptured, are more often brought to view on the 
operating table and in the post-mortem room. They are 
usually single, but may be multiple. As intestinal rup- 
ture is usually the consequence of a severe trauma in the 
neighborhood of the sympathetic centers, the classical 
symptoms of shock generally develop. Retroperitoneal 
emphysema signifies injuries to the duodenum or colon. 
Fecal matter is less apt to escape than gas, but the latter 
may escape in very small quantities. Vomiting is con- 
sidered of great diagnostic importance by many. As to 
prognosis, Siegel gives the following statistics; In cases 
operated upon in the first 4 hours, the mortality is 15.2 
per cent. ; in the first 5 to 8 hours, the mortaUty is 44.4 
per cent.; in the first 9 to 12 hours, the mortality is 63.6 
per cent.; in those operated upon later, the mortality is 
70 per cent. The writer states that in all cases of ab- 
dominal contusions the prognosis should be guarded, and 
the patients ought to be kept under careful observation. 
When there is the least suspicion of rupture, immediate 
laparotomy should be performed. The writer advises 
the incision made through the hnea alba below the umbiH- 
cus, as giving a better survey of the abdomen. The bowel 
should be examined methodically from a fixed point till 
the lesion is found. When for some reason operation 
cannot be performed, and an expectant course is followed 
in simple contusion or in cases of ruptured intestine, the 
patient should be placed at rest with an ice-bag on the 
abdomen. Nourishment should be given only bv rectal 
enemata. Opium is indicated to diminish peristaltic 
action of the bowels. 

The Envelope of the Red Corpuscle and Its Role in- 
Haemolysis and Agglutination. — S. Peskind gives the fol- 
lowing r&um^; Various facts of an historical, chemical, 
and physical character show that the red blood corpus- 
cles possess an envelope. From the action of hydroxy- 
lamine hydrochlorate, it appears most probable that the 
envelope is not a differentiated membrane, but a part of 
the stroma which is condensed to form the surface laj-er 
of the corpuscle. The envelope is hcemoglobin-free and 
consists of nucleoproteid cholesterin, lecithin, and mineral 
constituents. It is elastic, smooth, and apparently 
pot. esses a certain glaze which presents the agglutination 
of normal corpuscles with each other and makes them less 
accessible to the action of toxins. Agglutination of blood 
corpuscles is due to an effect on the envelope produced by 
various biological products and chemical reagents whereby 
the envelope is made sticky. .Agglutinins probably lower 
the resistance of the blood corpuscles forward toxins and 
other agents. From the fact that in nature they almost 
always occur in company with a hasmolysin, it is suggested 
that ' the agglutinins bear some cooperative relation to 
the haemolysins similar to that existing between the in- 
termediarv bodv and the complement. The "resistance" 
of blood corpus'cles depends in large part upon the con- 
dition of the envelope. Toxins of disease cause the en- 
velope to deteriorate, either partly or completely. " Vac- 
uohzation of the hasmoglobin " can be explained satis- 
factorily on the assumption of a minute lesion in the en- 
velope, which allows the surrounding fluid to enter and 
thus permit, of a locaHzed laking at this point. The func- 
tion of the envelope is, in part, to make possible various 
metabolic processes, principal among which is the com- 
plex process known as internal respiration. Another 
important use is to protect the corpuscles from deleter- 
ious substances. But the very chemical constitution of the 
the envelope may at times serve for the undoing of the 
corpuscles. 

Health of the Russian Army. — An official report from 
Manchuria states that up to June 26 the officers and 
men in hospital reached a total of 7.136 per cent, and 
3.943 per cent, respectively of the whole force. After 
the rains began the percentage of officers in the hospitals 
increased to 8.383 and of the men to 4.646. The pro- 
portion of infectious cases rose from 2.19 to S.52, in- 
cluding 1.99 percent, of dysentery. 



112 



MEDICAL RECORD. 



[July i6, 1904 



Materia Medica, Pharmacology, and Therapeutics. 
Inorganic Substances. By Charles D. F. Phillips, 
M.D., LL.D. (Abdn. and Edin.), F.R.S. and F.R. 
C.S. (Edin.). Hon. Fellow Medico-Chirurgical College, 
Pennsylvania; Member of the Academy of Medicine of 
America; Examiner in Materia Medica, University 
of Aberdeen, Late Examiner in the Universities of 
Edinburgh and Glasgow; Member of the Physi- 
ological Society of London; Late Lecturer on Materia 
Medica and Therapeutics at the Westminster Medical 
School. Third Edition London, New York, and 
Bombay: Longmans, Green & Co., 1904. 
This is a book of exceptionally practical value, full of 
useful suggestions, and one that cannot fail to be of 
ser\'ice to the physician in his fight with disease. The 
greater part of each section is devoted to the indications 
for the therapeutic employment of the drug under con- 
sideration, though sufficient space is accorded to a dis- 
cussion of physiological action and to the preparations and 
dosage of the remedies. The author speaks out of his 
own experience in the treatment of disease, and this 
gives to the book the charm and value of the personal 
touch associated with the clinical lecturer; but at the 
same time he does not ignore the discoveries of others in 
the same field. 

The chief fault with the book is the lack of system in its 
arrangement. Under the heading of "water," for ex- 
ample, sun baths and air baths, the Finsen light, and 
electric baths are treated of. and as there is only a thera- 
peutic index and none of remedies the matter is prac- 
tically inaccessible. An index of remedies would have 
obviated this objection ; one was in the former edition, and 
we cannot but think the author has made a mistake in 
omitting it from this edition. 

Le Malattie DEI Paesi Caldi, Lord Profilassi ed 
Igiene, con un' appendice; La vita nel Brasile. Rego- 
lamenti di Sanitd pubblica contro le infezioni esoticne. 
Pel Dottor Carlo Muzia. Con 154 incisioni en tavole. 
Milano: Ulrico Hoepli, 1904. 
The author of this volume is a surgeon in the Italian 
Navy. The subject is treated imder seven heads : General 
diseases, local diseases, diseases and lesions produced by 
animals and animal parasites, intoxications, cosmopolitan 
diseases occurring in the tropics, insolations, and hygiene 
of the tropics. The work is copiously indexed, and 
contains a bibliography of the principal works on the 
subject. While the size of the work precludes any 
monographic presentation, the terseness of expression 
enables the author to present much in the space at his 
disposal. The illustrations relate chiefly to the micro- 
organisms of the various diseases, and corresponding 
to the disproportionately large number of parasitic 
diseases the illustrations of the animal parasites are 
numerous. Maps are also given showing the geographical 
distribution of several of the more important diseases . 
Physiology and Pathology of the Uri.\e. With 
Methods for Its Examination. By J. Dixon Mann, 
M.D., F.R.C.P., Physician to the Salford Royal Hos- 
pital; Professor of Forensic Medicine in the Victoria 
University of Manchester. With Illustrations. Lon- 
don: Charies Griffin & Co., Ltd.; Philadelphia: J. B. 
Lippincott Company, 1904. 
And still they come! " Another book on the virine! "Wer 
reitet so spiit durch Nacht und Wind ? " It is an English- 
man this time, but what he has given us is a genuine sur- 
prise. A book not of the type" of the now so frequent 
'guides to the examination of urine." It differs from 
them in its thoroughness, completeness, and up-to-dateness. 
Some of the constituents of the urine, irrespective of 
their chemical constitution, have been grouped together 
to facilitate their study ; a description is furnished of the 
systemic conditions in which each urinary component 
appears in anomalous quantities; the more important 
pathological states, recognizable by specific alterations 
in the urine, are separately dwelt upon; and the results 
of the latest studies in metabolism, so far as affecting the 
urine, are given in just sufficient minuteness to be of 
real assistance to the investigator. 

The titles of the various sections will demonstrate the 
practical value of the book: General Characteristics of 
the Urine, Inorganic Constituents, Organic Constituents, 
Amido and Aromatic Acids, Carbohydrates, Proteids, 
Nitrogenous Substances, Pigments and Chromogens, 
Blood-coloring Matter, Bile Pigments, Bile Acids, Ad- 
ventitious Pigmentary and Other Substances, Special 
Characteristics of Urine, Urinary Sediments, Urinary 
Calculi, Urine in Its Pathological Relations. 

The subjects treatcd''upon in the section on "Special 
Characteristics of Urine" being particularly useful to the 
progressive clinician and impressing upon the book the 



stamp of modernity, are: Reducing Power, Oxidative 
Power, Proteolytic Power, Toxicity, Molecular Concen- 
tration (Kryoscopy), Conductive Capacity, and Calori- 
metry. 

The illustrations are of the stereotype variety and 
mediocre; the stronghold of the otherwise superb book 
does not lie in its chapters on the microscopy of the urine. 

BeRICHT UBER GaLLENSTEINLAPAROTO.MIEN AUS DEM 

letzten Jahr; unter gleichzeitiger Beriicksichtigung 
der nicht operirten Falle. Von Prof. Hans Kehr. 
Munich: J. F. Lehmann, 1904. 
This contribution to the subject of gallstone surgery 
forms part of the annual report of Kehr's private sur- 
gical clinic in Halberstadt, Germany. During the past 
year he had the opportunity of examining over 300 cases 
of cholelithiasis and performed an operation in 13^ of 
Ihese. The particular points to be noted in his technique 
are the disinfection of the hands with soap and water and 
alcohol (no bichloride); the most stringent asepsis; 
gastric lavage before operation in almost all cases ; nitrous 
oxide and chloroform anaesthesia; restricted numbers 
of nurses and assistants ; the use of silk and sterile gauze, 
neither catgut nor iodoform gauze being employed. Al- 
though Kehr does take an extreme view as to early opera- 
tion, and recognizes that a so-called latent period comes 
on spontaneously in about two-thirds of the cases. This 
is the reason why various internal methods of treatment 
are often followed by such favorable results; the latter 
are post hoc, not propter hoc. Kehr has recently traced 
about two-thirds of the last series of 500 cases which he 
operated iipon for gallstones. About 90 per cent, of 
these remained free from colic, icterus, and hernia, and 
were completely cured. 

The Medical News Pocket Formulary. By E. Quin 

Thornton, M.D., Assistant Professor of Materia 

Medica in the Jefferson Medical College. New (Sixth) 

Edition, Revised. Philadelphia: Lea Brothers & Co., 

1904. 

This collection of prescriptions seems to have taken well 

with physicians. The diseases are printed in large type 

and alphabetical order, so that reference is easy. There 

are 287 pages of small type. There is a useful table of 

doses, and the revision has brought the matter well up 

to the times. 

The Medical Epitome Series of Pediatrics. A 

Manual for Students and Practitioners. By Henrv 

Enos Tuley, A.B., M.D. Edited by V. C. Pederson, 

A.M., M.D. Philadelphia and New York: Lea Brothers 

& Co., 1904. 

This little book is intended as a pocket guide to the 

beginner in medicine. It deals with the pathology, 

diagnosis, and treatment of the diseases common to 

children. After each chapter a series of questions and 

answers are inserted to bring out the most valuable 

points. It also gives many points on the differential 

diagnosis. The author has contributed very frequently 

to pediatric literature and is entitled to a hearing. The 

chapter on infant feeding is quite complete. In a future 

issue the vital points concerning the brain and nervous 

system should be incorporated, as well as a chapter on 

intubation. 

Lectures on Clinical Psychiatry. By Prof. Emil 
Kraepelin. Authorized Translation from the German 
by Dr. James Johnstone. New York: Wm. Wood & 
Company, 1904. 
This is a volume of 300 pages containing thirty clinical 
lecturers on the commoner varieties of insanity, such 
as Melancholia, Manic-depressive Insanity, Dementia 
Praecox, General Paresis, Epileptic Insanity, Puerperal 
Insanity, Insanity after acute diseases. Paranoia, the 
insanities of alcoholism, morphine and cocaine, Trau- 
matic Insanity, Imbecility, Cretinism, Different Forms of 
Delusion, Compulsory Ideas and Irresistible Fears and 
Morbid Personalities. The lectures are simple, readable, 
and will undoubtedly be very acceptable to American 
physicians. During the last few years the classification 
of Kraepelin and the nomenclature which has grown out 
of the classification have taken a firm hold upon young 
American psychiatrists, and, although at the present 
time there are indications that the teachings of Wernicke 
are gradually gaining ascendency, still the followers of 
Kraepelin are many in this country. The book makes 
no attempt to cover the entire field of psychiatry but 
rather to deal with the familiar forms of alienation. Nor 
is there any space devoted to discussions of classification 
or theories of the pathogenesis of insanity. The general 
practitioner, especially if he is not familiar with the 
author's views, will find this volume of great aid in the 
interpretation of mental cases encountered in his practice, 
and the specialist will find it a valuable clinical com- 
pendium, to be used in connection with the treatise on 
msanity by the same author or any of the other standard 
works. 



i 



July i6, 1904] 



MEDICAL RECORD. 



1^3 



AMERICAN GYNECOLOGICAL SOCIETY. 

Twenty-ninth Annual Meeting, Held in Boston, Mass., May 

24, 25, and 26, 1904. 

Tuesday, May 24— First Day. 

The society met in the Boston Medical Library under the 

presidency of Dr. Edward Reynolds of Boston. 

An address of welcome was delivered by Dr. Charles M. 
Green of Boston, which was responded to by Dr. Henry 
T. Byford of Chicago. 

Treatment of Gallstones Found as a Coincidence in Ab- 
dominal or Pelvic Operations. — Dr. John G. Clark of 
Philadelphia stated that among the imsettled questions 
in abdominal surgery, the treatment of gallstones fovmd 
as a coincidence in abdominal or pelvic operations might 
be considered a debatable one. He followed the plan at 
present of removing gallstones which were found in the 
course of another operation, if the patient's condition 
permitted of this extra operation. Although it was stated 
that 95 per cent, of gallstones produced no symptoms, he 
believed that this statement should not be applied to cases 
as one met with them at the time of an operation. In his 
review of recent literature he had been especially im- 
pressed with the fact that knowledge of the early stages 
of cholelithiasis was verj- indefinite, and that many cases 
which came to operation for more or less urgent s)-mptoms 
did not have the clinical symptoms of colic and jaundice, 
as usually taught in medical schools. In view of this 
hiatus in the early history'of this disease, he believed that 
many symptoms now attributed to gastralgia, indigestion, 
functional disturbances of the gastrointestinal tract, etc., 
would, as knowledge increased, be ascribed to the presence 
of gallstones with associated infection, which was so fre- 
quently found in cholelithiasis. 

In referring to the etiology of gallstones, he said that 
three facts had been prominently established: (i) That 
the bile was not bactericidal. (2) That the microorgan- 
isms in the gall-bladder were predisposing, if not absolute, 
causative factors in the formation of gallstones. (3) 
When gallstones were present in the gall-bladder, infection 
in that viscus was much more likely to take place. 

He mentioned three general avenues through which 
infection might enter the gall-bladder, (i) From bac- 
teria circulating in the genital blood stream and reaching 
the liver through the hepatic veins; (2) by the direct 
passage of bacteria into the common bile duct from the 
duodenum; (3) by the transportation of bacteria from 
the intestine through the portal circulation. 

He then recurred to the frequently quoted statement 
that 95 per cent, of gallstones did not produce symptoms, 
and showed from his own series of cases that in at least 
50 per cent, there were varj'ing symptoms from undoubted 
attacks of colic and jaundice to less pronounced gastro- 
intestinal symptoms. To justify operative intervention 
in cases which were not producing well-defined symptoms, 
the mortality and morbidity should be a very low one. 
In his own experience no death had occurred, nor had 
there been any serious complication referable to the 
secondary operation. In lieu of the fact that the addi- 
tional operation did not seriously jeopardize the life of the 
patient, and also because he had seen two patients die 
from cholelithiasis a year or more subsequent to an ab- 
dominal operation, in which, had the routine exploration 
been made, the gallstones might have been easily removed, 
he believed that the best interests of the patient would be 
conserved if the gallstones were removed as a secondary- 
part of another operation, in the event of their being 
found. He appended the history of twelve cases to his 
paper, in which the various operative points, as well as 
the significant facts in symptomatology, were elaborated. 
Dr. R. Stansbury Sutton of Pittsburg said that gall- 
stones did not always produce symptoms which demanded 
or justified resort to operation. If they were encoiuitered 



during the course of another operation, they had better 
be removed. 

Dr. George M. Edebohls of New York had occasion at 
one time to operate on a woman who presented marked 
dyspeptic symptoms. In addition, she had movable 
kidney, chronic appendicitis, and induration in the region 
of the gall-bladder. He anchored the kidney, removed 
the appendix through a lumbar incision, pulled the gall- 
bladder into the lumbar wotmd, and found the stone about 
four or five centimeters in length, pear-.shaped, and nearly 
filling the gall-bladder. The attending physician w-as 
positive that the gall-bladder did not produce symptoms 
of stone in it. He would not let him remove the stone 
from the gall-bladder. A year later he opened the woman's 
abdomen for some other condition, making an incision 
near the gall-bladder. He investigated the gall-bladder, 
found it was perfectly healthy, and that the large stone 
had either passed or had been dissolved. The treatment 
after the previous operation consisted of the use of olive 
oil for about a month, and whether this had anything to 
do with the passage of the stone, he did not know. At 
any rate, the stone had disappeared and had left no trace 
of its former existence. 

Dr. A. Palmer Dudley of New York emphasized the 
importance of looking beyond the gall-bladder for trouble. 
He believed that stones were formed in the liver ducts 
themselves, and that from a stagnant circulation cholester 
in nuclei formed, and that only a small proportion of 
stones were foimd in the gall-bladder. He would not 
hesitate to go into the center of the liver. In fact, in the 
last case he had, in which the diagnosis of gallstones had 
been made by a medical confrere, he boldly went into the 
gall-bladder, but found no stone. He found the duct 
dilated ; he went five inches into the right lobe of the liver, 
as far as he could reach with his finger, and packed the 
liver full of iodoform gauze, put an apron of gauze over 
it, and the patient was well to-day. He would explore the 
center of the liver in searching for such deposits. 

Dr. Brooks H. Wells of New York said that in the 
last few years he had used practically the same measures 
as those outlined by the essayist. A number of patients 
coming under his observation had complained of obscure 
symptoms, of so-called functional indigestion. In them 
he found either disease of the gall-bladder, an over-dis- 
tended gall-bladder from obstruction elsewhere, or trouble 
referable to gallstones.. By making a small or large in- 
cision, as seemed necessary, cleaning out the gall-bladder 
and draining it, the patients had obtained remarkable 
relief from the symptoms that were supposed to be due 
to functional indigestion. 

Dr. Seth C. Gordon of Portland, Me., said that when 
the abdominal cavity was opened for other purposes, and 
he was quite sure the patient could stand it, he would ex- 
amine the gall-bladder thoroughly, and if gallstones were 
found, he would remove them. He cited cases in support 
of this line of reasoning. 

Dr. Hiram N. Vineberg of New York said that under 
the influence of the teaching of Kelly he had been in the 
habit of doing what had been advocated by the essayist, 
but after hearing a discussion on gallstones in the common 
duct and in the gall-bladder by one of the Mayos, he had 
changed his method. Simply opening the gall-bladder 
and removing the stones did not effect a cure, as proven 
by three or four cases that occurred in his own practice. 
If the gall-bladder was diseased, however, it should be re- 
moved. 

Dr. J. M. Baldy of Philadelphia said that gallstones 
existed in the gall-bladder for years without causing any 
material discomfort, but that when infection occurred 
they were liable to give trouble. There was not the slight- 
est question but what large numbers of cases of so-called 
stomach trouble, or chronic indigestion, sooner or later 
proved to be cases of gallstones or of gall-bladder disease. 
With reference to removing gallstones when operating 
for some other intraabdominal condition, the surgeon 



114 



MEDICAL RECORD. 



[July 1 6, 1904 



should consider the physical condition of the patient, the 
surroundings, etc., and as to whether the patient was 
willing to imdergo the additional risk o£ a second incision 
for the gall-bladder operation. 

Dr. Walter P. Manton of Detroit quoted Ochsner as 
saying that he had tried almost everything in the so-called 
cases of chronic dyspepsia, without affording relief; yet 
after opening their gall-bladders and removing gallstones 
which were found, the patients were cured. Dr. Manton 
had seen a number of such cases, and contended that the 
removal of gallstones, or the gall-bladder, if diseased, was 
the thing to do. He did not believe there was any solvent 
ever invented which could dissolve gallstones. 

Dr. Beverly MacMonagle of San Francisco, Cal., 
stated that when the abdomen was opened for some pel- 
vic or abdominal trouble, the operator should investigate 
the gall-bladder. If gallstones had been making the 
patient ill, causing dyspepsia, or if there were adhesions 
around the gall-bladder, one should operate. The con- 
ditions that arose in the pancreas as a consequence of gall- 
bladder disease and of gallstones were serious, and if the 
surgeon could do something of a prophylactic nature, 
without adding to the risk of the patient's life, it was a 
wise thing to do. 

Dr. Clark, in closing, said the formation of gallstones 
through bacteria had been clearly demonstrated by a 
series of experiments. He did not believe anyone would 
strongly advocate operation unless the gallstones were 
producing symptoms. 

Ovarian Pregnancy. — Dr. J. Clarence Webster of 
Chicago reported a case of ovarian pregnancy. There 
was a right ovarian irregularly rounded swelling, measur- 
ing 7 by 8 cm. There was no evidence of rupture into 
the peritoneal cavity. The adhesions were recent. Sec- 
tions of the ovarian swelling consisted mainly of extrav- 
asated blood and disseminated fragments of the chorion. 
No evidence of transformation of ovarian connective 
tissue into decidua was noted. It was certain that the 
pregnancy did not start in a Graafian follicle. 

Dr. J. Whitridge Williams of Baltimore said there 
was no doubt that ovarian pregnancy occurred, but it 
was the rarest of all forms of extrauterine pregnancy. In 
regard to the Muellerian origin of ovarian pregnancy, he 
was not quite convinced of it. While there was no doubt 
that Muellerian tissue might be found in the ovary, as 
mentioned by the essayist and confirmed by numerous 
observers, he thought it was going too far to advance that 
view in explanation of every case of ovarian pregnancy. 

Dr. John T. Thompson of Portland, Me., referred to 
a case of ovarian pregnancy he had reported at a previous 
meeting of the society. He called attention to the nature 
of the structures in which pregnancy occxirred, and to the 
frequency with which rupture might occur in the early 
days. 

Dr. Edward P. Davis of Philadelphia removed an 
ovarian pregnancy about a year ago, the histology of 
which had not been completely worked up as yet, although 
a diagnosis was made very early of the nature of the tumor 
from the enlarged ovary. The indications were that the 
pregnancy did not originate in the Graafian follicle. 

Dr. Lapthorne Smith of Montreal had diagnosed 
ectopic pregnancy by the clinical symptoms; had op- 
erated, and had found hsematoma of the ovary. He had 
said to his students that lie was sorry that his diagnosis 
was wrong, because authorities maintained that there was 
no such thing as ovarian pregnancy, but after hearing 
what had been said he was convinced there was. 

Ureterolithotomy. — Dr. J. Wesley Bovee of Wash- 
ington, D. C, in a paper on this subject, gave the history 
of the operation, and then discussed the size and number 
«f calculi. The routes for reaching and extracting 
ureteral calculi, he said, were the transperitoneal and the 
extraperitoneal. The latter might be subdivided into 
loin, inguinal, vaginal, rectal, sacral, perineal, and trans- 



vesical. The transperitoneal route should never be the 
one of election, as the danger of peritoneal infection from 
the urine was too great. Of the extraperitoneal routes, 
the selection would depend largely upon the location of 
the calculus or calculi, although the operation of Ceci,of 
removing it through the rectum, should only be considered 
justifiable when the stone had practically sloughed 
through into the rectum. In a class of cases characterized 
by the stone having been lodged in the intravesical portion 
of the duct and later sloughed into a pocket in the bladder 
wall, which it had made for itself, the vaginal and inguinal 
routes were the only safe ones, although in so stating he 
was not unmindful of the number of cases in which supra- 
pubic cystotomy had been done. He discussed the re- 
moval of the calculus from the ureter, and the methods 
for so doing; also the treatment of the ureteral opening. 

Speaking of drainage, he stated that all ureterolithot- 
omy wovmds should be drained. This was because the 
urine was practically never normal, therefore rendering 
wound infection probable. The possibility of urinary 
leakage subsequent to operation afforded another positive 
indication for drainage. 

Nephrectomy for Primary Tuberculosis of the Kidney. — 
Dr. Hiram N. Vineberg of New York read a paper on 
this subject. Tuberculosis of the kidney, both primary 
and secondary, was more frequently met with in women 
tlian in men, in the proportion of about two to one. It 
was different from what occurred in men ; renal tuber- 
culosis in women was rarely associated with tuberculosis 
of the genital organs. A cystitis in women that resisted 
the topical applications of the silver nitrate solution by 
the Kelly method should be looked upon with naarked 
suspicion as being of tuberculous character, even though 
repeated examinations of the urine should show an ab- 
sence of the tubercle bacillus. The differential diagnosis of 
a non-tuberculous from a tuberculous cystitis with the 
aid of the cystoscope was not as reliable as the therapeutic 
test outlined in the preceding sentence. Pronounced red- 
deningor ulceration about the mouth of one of the ureters, 
with absence of other bladder changes, was held bj' some 
authorities as pathognomonic of tuberculosis of the corre- 
sponding kidney; while the sign was an important one, 
too much weight should not be attached to it in women. 
In most cases the removal of the diseased kidney wovdd 
bring about practically a cure of the descending cystitis. 
He doubted the wisdom of the advice to cure the cystitis 
before imdertaking the removal of the kidney in women, 
owing to the fact that the disease was most frequently 
primary and unilateral, the modem tests for determining 
the functional capacity of the second kidney were not as 
essential as in men. Catheterization of the supposedly 
healthy kidney was a procedure to be avoided, when, as 
was frequently the case, there was associated a tubercu- 
losis of the bladder. The prognosis of nephrectomy in 
renal .tuberculosis in w-omcn was exceedingly good. Of 
the writer's four cases operated upon, seven, five, two, and 
one and one-half years ago, respectively, all were alive and 
in good health. 

Dr. Joseph E. Janvrin of New York reported a case 
of a woman who had been ailing for two years with what 
was supposed to be a renal calculus. Before operating, 
Dr. Willy Meyer examined the woman, and agixed with 
him that the case was probably one of calculus in the 
pelvis of the kidney, with possibly calculi in the tireter. 
The kidney was removed, and it was found that the pelvis 
was infiltrated with tuberculous deposits in the very early 
stage. The patient made a good recovery and was well 
to-day. 

Dr. J. Wesley Bovee said that if one read the proceed- 
ings of the late meeting of the German Congress, he vould 
be impressed with the comparatively large proportion of 
cases in which primary tuberculosis was found in both 
kidneys, or the very small proportion in which one kidney 
alone was involved. As to the indications for operation, 



July 1 6, 1904] 



MEDICAL RECORD. 



"5 



on tuberculous kidney, the surgeon should be sure that 
the opposite kidney was capable of carrying on the func- 
tion of excreting urine for the whole body before he 
decided to remove one tuberculous kidney. A nephrot- 
omy might be done, and the kidney most markedly dis- 
eased drained, without taxing the other kidney to a great 
extent. As regards cystitis in tuberculosis of the kidney, 
it was a late, not an early, symptom. 

Dr. Philander A. Harris of Patcrson, N. J., said that 
in cases of tuberculosis of the kidney it was difficult, when 
the bladder was corrugated and changed by the pathology 
present, to find the ureter; but by painting the entire 
field of the bladder with some solution sufficiently colored 
with a swab, as Prussian blue, he had succeeded in finding 
the ureters in the case of a girl which he could not other- 
wise locate. 

Dr. Seth C. Gordon operated on a man, removing a 
kidney which was situated low down in the abdomen, 
painful, and bound down by adhesions. The patient 
died eleven days after the operation, and post-mortem 
examination showed that the man had no other kidney. 
Two years afterward he removed a very large kidney from 
a woman, who lived twenty-eight days after operation. 
For twelve hours she did not have a single uraemic symp- 
tom, nor was there a drop of urine secreted, and she died 
in full possession of her faculties. Post-mortem exam- 
ination revealed that she had no other kidnej'. 

Dr. J. M. Baldy said it was not uncommon to have 
medical men in the wards of the policlinic ask if the ureters 
had been catheterized in the cases of supposed kidney 
disease, and not infrequently a perfectly healthy kidney 
was palpated and found on one side which utterly failed 
to secrete with the patient under an anEesthetic or without 
it. In some instances this failure on the part of the kidney 
to secrete was imdoubtedly brought about by the in- 
fluence of the anaesthetic. At any rate, anesthesia would 
reduce the quantity of secretion very materially. He 
had had exactly that same experience a number of times 
in patients whose ureters he had catheterized, but to 
whom no anjesthetic had been given. 

Dr. George M. Edebohls said that some four or five 
years ago he read a paper on "The Other Kidney and Con- 
templated Nephrectomy." In it he advocated that 
before removing a kidney an incision should be made on 
the opposite side to determine by actual inspection and 
palpation (i) the presence of another kidney, and (2) 
its probable health, so far as could be determined macro- 
scopically, before removing the diseased kidney. In 
spite of the advance made in diagnosis, and its limitations 
in kidney diseases, he had adhered to that rule in all 
nephrectomies performed since that time, and in one case 
he had saved a woman's life by so doing. 

Dr. J. Riddle Goffe of New York reported a case bear- 
ing on the removal of the ureter in connection with tuber- 
culosis of the kidney, the patient having been operated on 
by him in 1896. She was a woman of twenty-two, who 
had a very large tuberculous abscess of the right kidney. 
He removed the kidney and three inches of the ureter. 
She made an excellent recovery, excepting that she had 
a sinus which lasted four months and then healed. Pa- 
tient was now a graduate nurse and in perfect health. 

Dr. Edward Reynolds of Boston gave his experience of 
ten nephrectomies for tuberculous disease, seven of them 
being complete nephro-ureterectomies, all successful, so 
far as operative mortality was concerned. 

Hypertrophies and Inflammations about the Urinary 
Meatus. — Dr. Robert L. Dickinson of Brooklyn read a 
paper on this subject, saying that their fnqutncy, and 
the suffering caused, gave them an importance out of all 
proportion to their minute size. Overlooked because 
hidden among folds of mucous membrane. They were 
explained bj' embrj'ology. A tiny ribbon ran from the 
rear of the vaginal opening forward, on each side of the 
vaginal and urethral openings, across the vestibule to 
disappear beneath the clitoris. This fold was persistent in 



those cases in which the hymen ran forward of the meatus, 
or the meatus seemed to open on the anterior vaginal 
wall. This fold was enlarged by friction or traction to 
produce flaps or labia, hanging out each side of the meatus. 
They were fotmd only with corrugated labia. Dilated 
or dilatable urethra often accompanied thim. The 
urethral glands opened near the apex of the flaps. They 
were long, running down into the anterior column of the 
vagina. Swelling from infection differed from hyper- 
trophy. The cure of chronic inflammation was only 
feasible by obliteration of the glands. A fine probe, 
passed to the bottom of the gland, rendered the vestibular- 
vaginal surface tense; the cautery wire cut out the probe. 
For piles of the meatus, the cautery wire was used after 
cocaine ; for prolapse or dilatation of the urethra, resection 
of the anterior vaginal wall or paraffine injections into the 
urethrovaginal septum produced a sigmoid profile. 

Surgery of the Female Urethra — Dr. Ely Van de War- 
ker of Syracuse, N. Y., read a paper on this subject. The 
urethra, he said, appeared like an insignificant part, its 
vital relations were negligible, its anatomy was relative, 
and acquired its importance from its related organs, but 
it might be said to epitomize a large share of the sufi'ering 
that woman's pelvic organs inflicted upon her. The 
amoimt of disturbance caused by- a simple irritation of 
the urethra to the bladder and indirectly to the kidneys 
afforded striking proof of the validity of reflected nervous 
disturbance. 

The term sacculation was regarded as better than the 
old one, urethrocele. Its major cause was mechanical, 
as inflammation alone was not adequate to its production. 
The lu-ethra might be said to belong to the perineal rather 
than the pelvic zone of organs. The walls of the canal 
depended in a meastire upon the support of the perineal 
body. It was often associated with long-standing rupture 
of this part. Restoration of the perineum was therefore 
essential to treatment of the sacculation. When large, 
an elliptical flap of the walls of the urethra was removed 
and the edges brought together by fine silk sutures. Pro- 
lapse of the mucous lining of the urethra the author had 
generally associated with long-standing urinary troubles 
of various kinds. It was, therefore, probably due to a 
gradually progressive condition, and was a typical ptosis, 
and complied with the general law of genital prolapse. 
After removing the prolapsed portion there was a marked 
tendency to recurrence unless the conditions which gave 
rise to it were treated and cured. Bladder incontinence 
and dribbling were often lifelong conditions. That this 
was due to a defective action of the sphincter vesicae was 
more than doubtful. 

Stricture of the urethra, in the author's experience, was 
common in women. Any condition that tended to pro- 
duce linear or annular thickening led to stricture. 
Specific urethritis might produce stricture, but it was not 
the frequent cause alleged by some writers. Stricture of 
large caliber might be located and measured by the Otis 
bulbs, but never by the sound, as was recommended by 
old systematic writers. Annular stricttu-e of the meatus 
was the form most commonly met with. These ought to 
be incised and made to heal in an open condition by the 
frequent passage of the sound. Dilatation alone was too 
painful and required too much time. As to eversion of 
the mucous membrane at the meatus, its prototype was 
the fusiform stricture of Otis, and its surest cure was by 
dilatation. 

Pyelitis Complicating Pregnancy. — Dr. Edwin B. 
Cragix of New York read this paper (see page 81). 

A Second Case of Puerperal Eclampsia Successfully 
Treated by Renal Decapsulation. — Dr. George .M. Ede- 
bohls of New York said the first case, reported to the 
society a year ago, illustrated the immediate cure by renal 
decapsulation of puerperal convulsions, recturing with 
great and increasing violence after the birth of the child, 
a period at which the hitherto final resource of forced 



it6 



MEDICAL RECORD. 



[July 1 6, 1904 



delivery was, of course, no longer available. In presenting 
the case the opinion was advanced that resort to renal 
decapsulation in the undelivered woman suffering from 
puerperal eclampsia might obviate the necessity of forced 
delivery. The case now reported illustrated the correct- 
ness of that opinion. Renal decapsulation was performed 
upon a woman pregnant near term, suffering from puer- 
peral eclampsia, and almost complete suppression of urine. 
The convulsions were arrested, the flow of urine was re- 
established, and a threatened death from uraemia was 
averted. Two daj's after all this had been accomplished, 
labor began spontaneously, and living twins were bom. 
One child died soon after birth. The second child and the 
mother were in perfect health four and a half months 
after the termination of pregnancy. Renal decapsulation 
thus became the rival of forced delivery in cases of puer- 
peral convulsions of renal origin in the undelivered woman. 
In puerperal convulsions, occurring or recurring after 
delivery, it constituted the final resort when all other 
measures had failed. 



Wednesday, May 25 — Second Day. 
Primary Repair of Lacerations of the Cervix Uteri. — Dr: 
Edward P. Davis of Philadelphia read the first paper in 
the symposium on this subject. Experience in fifty-three 
caseshad led to the following conclusions : When the patient 
was not infected and when the tissues had not been sub- 
jected to sufficient violence to threaten necrosis and 
laceration of the cer\'ix, one-half inch or more in extent 
was present, primary closure had been followed in his 
experience with good results. These cases usually oc- 
curred in primiparae in whom resistance in the soft part 
occasioned sufficient delay and fatigue to require de- 
livery by forceps. They were also seen in cases of prema- 
ture labor, whether spontaneous or induced, in which the 
cervix was not phy.siologically softened for perfect dilata- 
tion. They were also found in patients having spon- 
taneous labor with very strong expulsive efforts, and 
with large children. Naturally those cases in which the 
mechanism of labor was abnormal through posterior 
rotation of the occiput, face presentation or breech presen- 
tation, predisposed to laceration of the cervix. While 
primary closure of laceration of the cervix was indicated 
in the conditions just described, certain conditions were 
necessary for its successful performance. These con- 
ditions were outlined. Dr. Davis then described the 
technique of the operation, and the after-treatment. The 
number of cases under observation was 53. In these, 
good union occurred in 45, fair union in 6, no union in 7, 
while infection developed in none. In 84.9 per cent, the 
operation was successful ; in 1 1.3 per cent, it was moderate- 
ly successful, and in 3.8 per cent, the operation failed. 
The percentage of infection was nil. He pointed out 
the objections which were commonly urged against this 
operation, after which he said that in appropriate cases 
in his experience immediate closure of the cer\ix had 
given no inconvenience to the mother, and had been fol- 
lowed by excellent results. The operation was not ad- 
vised for those who do not practise obstetrics with good 
surgical technique, and who were not competent to operate 
on the genital tract. 

Cervix Suture on the Fifth Day after Delivery. — 
Dr. RoBHRT L. Dickinson of BrookI\-n said that 
no complicated or considerable perineal injury should 
be repaired at the close of labor, but three to five days 
later. This had an important bearing on lacerations of 
the cer\'ix, as this was the ideal time to restore such in- 
juries. The huge oedema, the bruising, and the uncouth 
distortion of the vaginal portion just after delivery ren- 
dered identification of the parts that should be brought 
together impossible, and attempt to coapt accurately, 
guess w^ork. Therefore, whenever possible, the cervix 
should be sewed on the fifth day. The frozen sections of 
the puerperal weeks showed that then, and not till then. 



shrinkage had occurred. Bleeding no longer obscured 
the difference between flayed surface and torn structure. 
Then only were the svirroundings of the operation, in the 
way of illumination, table, time, and a rested personnel 
possible. This applied particularly to private practice. 
The conditions under which the cer\-ix should be repaired 
at the close of labor were: (1) Bleeding from a firmly con- 
tracted uterus, notwithstanding ergot, heat, holding, 
and tampon. Here there was a spurting artery. (2) 
When the cer\'LX injuries were clean cuts, of known loca- 
tion, as after Duhrssen incisions. (3) When, in the im- 
mediate repair of a moderate perineal injury, a tear of 
the cervix is found. The conditions under which the 
cervi.x should be repaired several days after labor were: 
Exhaustion of patient, or surroimdings and conditions 
which precluded careful work. (2) Extensive injuries, 
except when these persistently bled or had been cut by 
the surgeon. (3) When accompanied by complicated 
or considerable injuries to the pelvic floor. The author 
drew attention further to the alterations produced by 
granulation and contraction in these wounds when left 
alone, so that the scarred, swollen, averted, or cystic cer- 
vi.x months or j-ears after injury gave uncertain indica- 
tions for accurate restoration to the original condition. 

. General Considerations of Laceration of the Cervix 
Uteri. — Dr. J. M. Baldy of Philadelphia staled that 
as a matter of clinical fact, let the cer\ix uteri be torn 
deeply and if the parts were preserved from infection, 
the greater part of the tear would heal spontaneously, 
and the rest of it would remain perfectly healthy, as 
much so as would the lobe of the ear which had been torn 
through by the weight and drag of our great-grand- 
mother's earrings. The lips would remain tuiinfiltratcd, 
of normal size and thickness, with no eversions and no 
erosion of the lining mucous membrane. In such a 
case there would be no untoward symptoms and no bad 
effects whatever. There was a tendency amongst ob- 
stetricians to repair these lacerations primarily. The 
objections to such practice were manifold, and he ad- 
mitted a prejudice against it. These objections were 
pointed out. Whatever might be ideal surgery under 
the exigencies of actual practice, the treatment for 
recent lacerations of the cervix remained, and he be- 
lieved would remain, rigid local cleanliness, excepting 
where there was sufficient hemorrhage to demand a liga- 
ture. Where non-infection could be insured, and where 
the torn lips were not unnecessarily disturbed, by the 
careless use of the nozzle of a syringe, spontaneous healing 
of these lacerations might be expected to a greater or 
lesser degree, and what tear remained, when nature was 
through with her work, would be of a healthy character, 
would give no future trouble, and would need no surgical 
interference. The symptoms of chronic lacerations of 
the cervix uteri were essentially local in their production 
and remained so in their manifestations. He had no 
sym]:>athv with the views which attributed reflex symp- 
toms to these lesions. In uncomplicated cases, in which 
there existed simply a laceration of the cer\-ix uteri, with 
everted and eroded lips, producing a constant leucorrhoea 
and a feeling of weight and uneasiness in the pelvis and 
about the rectum, these so-called reflex symptoms did 
not exist. There was one belief prevalent which would 
warrant, nay demand, a repair of every lacerated cervix — 
the belief that lacerations of the cervix produced carci- 
noma. In this belief he took no part, and no one had, to 
his knowledge, as yet produced a single scientific fact 
which would uphold such a theory. In twenty years' 
work he had not seen a single case of cancer develop 
in a laceration of the cer\-ix which he had refused to 
repair. 

Intrapelvic Haematoma. — Dr. J. Wiiitridge Williams 
of Baltimore reported a case of intrapelvic haematoma 
following labor, and made some remarks on the treat- 
ment of incomplete rupture of the uterus. 



July 1 6, 1904] 



MEDICAL RECORD. 



II- 



President's Address. — Dr. Edward Reynolds of Boston 
in his presidential address, said, among other things, 
that the society owed its preeminence along its chosen 
line less to the words than to the prolonged and daily 
labor of the eminent men who had composed it in the 
past, and must owe its future to the lifework of the 
equally able men who were to fill its membership in the 
coming years. He said the use of the printed abstract 
pulilished beforehand had of late become increasingly 
prominent in many societies, and in the British Medical 
Association this use of the abstract had reached its 
highest terms. It was seldom wise to adopt wholesale 
the regulations of other organizations. It was usually 
better to let changes follow a more gradual and natural 
ev-olution under the needs of the individual a sembly, 
but the methods of the English association were worth 
a passing consideration. A Fellow of the British Medical 
Association who desired to present a paper at one of its 
meetings, must put it in the hands of the secretary com- 
plete and in the form in which he desired its publication 
a number of weeks before the meeting, and the com- 
munication might be of any length he chose. A paid 
secretary, a (lualified and experienced medical author, 
then abstracted each paper in the form and length which 
he considered best fitted for its public delivery. This 
official then read the abstracts to the society as they 
were called from the program. Such a reading inaugu- 
rated each discussion, and the member whose ideas had 
been thus succinctly set forth before his associates took 
part in the discussion and closed it. The ideas of indi- 
vidual members by this method were better and more 
intelligently presented to the society than if they had 
read their complete papers. In this way the time of 
the society was economized, full debate was encouraged, 
and the members had the advantage of publishing to the 
world papers in which their points were set forth at the 
fullest length and without time limitation. Dr. Reynolds 
said that such a method was perhaps too far advanced 
for our present needs or possibilities, yet it had many 
advantages, and it seemed to him worth calling attention 
to as one toward which the society might well advance. 

Would it not be wise to give this method, or a modifi- 
cation of it. a year's trial ? In conclusion he expressed 
his thanks for the kindly personal feeling which had 
actuated the Fellows when they elected him president, 
for which, and for the many personal pleasures which he 
had enjoyed in the society, he was, and would always 
gladly remain, their willing debtor. 

The Preventive Treatment of Pelvic Floor Lacerations.- — 
Dr. J. Clifton Edgar of New York read this first paper 
in a symposium on injuries to the perineum. The most 
important part of the management of the second stage of 
labor was the prevention of pelvic floor lacerations, 
lacerations of the fourchette in primipar^E, and superficial 
tears abotit the vulvar orifice in both primipara and multi- 
para often occurred, were often unavoidable, and usually 
readily healed with simple asepsis. Deep lacerations were 
avoidable in normal, ordinary cases of labor. The factors 
which tended directly or indirectly to produce pelvic floor 
lacerations were numerotis, but for convenience he ar- 
ranged these in three major classes. These were concisely 
stated as (i) too rapid expulsion of the foetus, so that 
tearing instead of stretching resulted. (2) Relative dis- 
proportion in size between the presenting part and the 
parturient outlet. (3) A faulty mechanism of labor, 
whereby the larger circumference of the head and shoul- 
ders than necessary passed through the parturient outlet. 

From an extended clinical experience, he covild speak 
most enthusiastically of the preliminary digital stretching 
of the vulvar outlet in primipara, and especially in elderly 
primipara, as a prophylactic measure in perineal pro- 
tection. Regarding shoulder delivery, the author firmly 
believed that the posterior shoulder was responsible for 
many instances of deep pelvic-floor laceration. Further- 



more, moderate ruptures caused by the passage of the 
head were often increased and rendered serious by 
the subsequent passage of the posterior shoulder. He 
had been most successful with the following method 
of shoulder dehvery, and either the lateral or dorsal 
posture of the patient could be used at will. This method 
was not new: (i) The delivery of the shoulders was de- 
layed, if possible, until nearly complete rotation of the 
bisacromial diameter had taken place. (2) The fetal 
head was taken in the hand and gently raised or pushed, 
so as to bring the anterior shoulder well up behind the 
symphysis, thus giving the cervico-acromial diameter of 
the foetus at the outlet instead of the bisacromial. (3) 
The posterior shoulder was now allowed to pass out spon- 
taneously and whenever possible manual extraction should 
be avoided, as this increased the risk of perineal rupture. 
(4) During the detention of the anterior shoulder behind 
the symphysis, the fetal hand of the opposite arm lying 
across the fetal chest would usually soon appear in the 
vulva. He had found that deUvery might be safely 
assisted by slowly flexing this forearm and arm out through 
the vulva and thus delivering the posterior shoulder by 
slight tracticn on the posterior arm. (5) Should the 
foregoing be impracticable and delay in the expulsion of 
the posterior shoulder occtir, he had found gentle traction 
upon the head, the fingers encircling the neck, to be prefer- 
able to traction with a finger in the axilla. (6) Should 
there be delay in the delivery of the anterior shoulder, 
after expulsion of the posterior, it was best remedied by 
making traction directly downward, with the hands placed 
on the sides of the head, taking care not to make too great 
pressure on the perineum. As a last resort, traction might 
be made by a finger in the axilla. 

Placing Sutures before the Lacerations Occur. — Dr. 
L.\PTHORNE Smith of Montreal spoke of the importance of 
closing up even small tears of the perineum, so as not to 
leave raw surfaces for septic absorption. It was impor- 
tant to close large tears eg as to retain the function of the 
pelvic muscles. The best time to put in these stitches was 
just before the head pressed on the perineum, while the 
patient was anaesthetized, and before the parts had lost 
their relative positions. With the left finger in the vagina 
and the thumb in the rectum, a large perineum needle on 
a handle was passed just under the vagina, threaded with 
silkworm gut ; the two or three stitches himg loosely in a 
Pean forceps until the placenta had been delivered, when 
they were quickly tied, bringing the parts exactly together 
as they were before the tear. 

Immediate Kepair of Injuries of the Pelvic Floor. — Dr. 
Henry C. Coe of New York said that he had selected this 
topic in order to emphasize the fact that by careful 
attention to puerperal lesions at the time of their occur- 
rence the patient could be spared much future trouble. 
He assumed that it was the usual practice of modem 
accoucheurs to repair injuries to the pelvic floor at once, 
but it was one thing to suture visible tears and another to 
repair deeper lesions. Even when perfect union of the 
lacerations was obtained, the occurrence of prolapsus, 
cystocele, and rectocele months afterward proved that 
there had been some fault in the technique. The fact of 
the separation of the fascia and leva tores ani muscles 
must be recognized as well" as the superficial tear, 
especially after difficult instrumental deliveries. An 
illustrative case from the writer's practice was cited. The 
tendency of the accoucheur after a tedious instrumental 
case, in which both physician and patient were exhausted, 
was to spend as little time as possible in repairing lesions 
of the soft parts, trusting to aseptic technique to insure 
perfect healing. The writer was firmly of the opinion that 
it paid to do the work thoroughly at the time, unless the 
patient's condition was such as to render delay advisable. 
He had had such good results from immediate operations 
that the intermediate did not appeal to him. In con- 
clusion, he alluded to the fact that the modem accoucheu 



ii8 



MEDICAL RECORD. 



Qtily 1 6, 1904 



must be a surgeon as well as an obstetrician. It was 
e.xpected of hini to leave the patient in as good condition 
as he found her, otherwise he properly laid himself open 
to criticism. 

Uniformity in Pelvic and Cranial Measurements. — Dr. A. 
F. A. King of Washington, D. C, read a paper on this 
subject in which he reached the following conclusions: 
"(i) That at present the measurements of the normal 
pelvis and fetal head are indefinite and unsettled, and must 
continue so to be so long as they are determined by our 
present methods of mensuration. (2) The chief purpose 
in obtaining the normal dimensions of these structures 
being £or teaching and learning the normal mechanism 
of labor, it is proposed to adopt an ideal or hypothetical 
head and pelvis, upon the dimensions of which all author- 
ities may agree. (3) In the adoption of such ideal struc- 
tures, it is imnecessary and undesirable to define any 
measurement with exact precision — no fraction smaller 
than one-fourth of an inch, or than half a centimeter (in 
the metric system) being required. (4) Race variation 
forms no real obstacle to the proposed plan, and other 
apparent difficulties can be overcome. Finally, should 
the proposition meet with approval, it is suggested that 
this society take the initiative in bringing the matter in 
proper form before some forthcoming international medical 
congress for general adoption." 

Accordingly, a committee was appointed by the presi- 
dent to consider the matter of imiformity in pelvic and 
cranial measurements, and report at the next annual 
meeting. 

Non-operative Local Treatment in Gynecology. — Dr. 
Willis E. Ford of Utica, N. Y., in reading the first paper 
in the symposium on this subject, said that no one would 
deny that greater good had come from surgical treatment 
of diseases peculiar to women than was ever dreamed of 
by the early gynecologists who did not operate. No 
comparison of results could be made. He did not think 
it was true, however, that the specialty ought to become 
purely surgical. Pathology learned by pehdc and ab- 
dominal Surgery ought to be clearer and better than was 
ever discovered post-mortem. It was fair to assiune 
that men who did this work had a better idea of the natural 
history, progress, and dangers of these diseases than those 
who did not operate; and that, therefore, the early treat- 
ment ought to be in the hands of men who were also doing 
surgical work. The nervous habit could not be cured 
by surgical procedure. What was commonly called 
neui asthenia was not a disease, but an established habit, 
possible only to those who had from birth an unstable or 
weak nervous constitution. Before the mental symp- 
toms began was the time to prevent neurasthenics from 
becoming permanent invalids. That the nervous habit 
could not be cured by surgery had been proven by the fact 
that the removal of diseased ovaries, and such like opera- 
tions on epileptic women, had not cured the epilepsy or 
neurasthenia. The argument, therefore, was that in those 
ailments that tended to disturb the emotions, especially 
those of the reproductive organs of men or women, the 
the serious thing was not the pain experienced, but the 
permanent invalidism which was brought about by the 
protracted local sensations that in time disturbed the 
mental equilibrium and brought about the invalid habit. 
These local irritations ought to be treated bv skilled 
gynecologists, and not allowed to develop either the men- 
tal or physical ailments which were so common a result. 
These arguments were enough to make the profession 
to revive its interests in non-operative procedures. Re- 
cent displacements, especially in young people, and acute 
infections were mentioned as demanding non-surgical 
care early, if one wished to avoid the more serious ailments, 
and especially the most serious of all, the mental disorder 
called neurasthenia. 

Dr. Walter P. M.^ntom of Detroit. Mich., said that 
the ignorance of proper methods, together with the fas- 



cinations of operative measures, had brought the local 
treatment of pelvic disease into disrepute. Three of the 
factors, which among others at the present time were 
largely responsible for the neglect of medical gynecologj". 
were: (i) The average physician's lack of knowledge 
in the accurate diagnosis and local treatment of pelvic 
disease. (2) The allurements and fascinations of sur- 
gery, and (3) competition in the field of practice. While 
it was true that no amount of instruction could impart a 
tactus eriidiins, stiU anyone could acquire a knowledge 
of the primary principles imderlying the correct inter- 
pretation of gynecic ailments, if opportunity was offered 
for the practical examination of patients imder competent 
direction. In ignoring the benefits to be derived from 
medicine, he was convinced that surgery had gone too 
far and that it had overshot the mark, but that the present 
tendency to operative measures in all conditions affecting 
the pelvic organs could not be ascribed so much to the 
good which surgerj-, rightly directed, was capable of 
accomplishing as to other elements which had entered 
into the case was also e\-ident. In the best of hands the 
results from local treatment in pelvic diseases were fre- 
quently slow in manifesting themselves, and discourage- 
ments were often met with, but in suitable cases persistent 
eflfort would ultimately attain the desired end. The 
objects of local treatment were the relief of pain and 
irritation, often of a reflex nature; the allaying of conges- 
tion and inflammation : the absorption of the products of 
inflammation, and the reposition of displaced organs. In 
the regulation of the uterine functions, in congestions 
and mild inflammations of that organ and surrounding 
parts, and in displacements of the uterus, w^th and without 
adhesions, the application of proper local treatment was 
of signal value; while in prolapse of the tubes and ovaries, 
even in the presence of extensive adhesions, but without 
. ascertainable morbid changes in the organs themselves, 
vaginal tamponade offered the simplest and most efficient 
means of reposition and cure. 

Treatment Preparatory to Operation. — Dr. Hexry C.Coe 
of Xew York introduced his remarks with the statement 
that while his early training had led him to believe that 
such treatment was practically indispensable in cases of 
so-called "cellulitis," subsequent experience had con- 
vinced him that this notion was not in accordance with 
pathology or common sense. He had expressed skepti- 
cism on this subject as long ago as 1S86, when he read a 
paper on the "Exaggerated Importance of Minor Pelvic 
Inflammation," and subsequent experience had only 
ser\'ed to confirm his opinion that old pelvic exudates and 
adhesions were not per se a contraindication to operations 
on the uterus. Modem aseptic technique was a suf- 
ficient safeguard against danger from this source. The 
reader contrasted the old practice of keeping a patient in 
a hospital for several months, with the preparatory treat- 
ment between each minor operation, w-ith the present 
plan of performing a combined operation at one seance 
and sending the patient out in three or four weeks. 
He questioned the actual value of the hot vaginal 
douche, local applications to the vaginal fornix, etc , 
previous to trachelorrhaphy. At the same time, he 
admitted the remarkable results often obsen-ed as 
regards the absorption of extensive pelvic exudates. 
.Acute and subacute inflammations in and around the 
adnexa formed the real contraindication to opera- 
tion, and doi^btless surgeons were not always as 
careful as those of the former more conservative genera- 
tion in selecting their cases. Competition and the rush 
of modem life were responsible for some ill-advised opera- 
tions, minor as well as major. In regard to major opera- 
tions, the author thought that (excluding pus cases) 
general preparatory' treatment of the patient was rather 
more important than local. He believed, however, that 
the admirable results obtained by the pioneers in the 
treatment of vesicovaginal fistula' were due to careful 



July i6, 1904] 



MEDICAL RECORD. 



119 



preparatory treatnaent, such as the division of cicatrices, 
stretching of the vagina, etc. Fortunately we were sel- 
dom called upon to handle such complicated cases as those 
described by Sims, Emmet, and Bozeman. With all our 
improvements in technique, we had not yet outgrown all 
the wisdom of our old teachers. 

Postoperative Local Treatment. — Dr. J. Riddle Goffe 
of New York said the experience of all observers was that 
local treatment relieved congestion, pain and discomfort; 
inaugurated, hastened, and accomplished the absorption 
of oedema, plastic exudate, adhesions, and pseudo-hyper- 
trophy. . If it wotdd relieve these conditions, how much 
more certainly would it prevent them.? It had been 
found serviceable in preventing the deposit of plastic 
exudate and the reformation of adhesions in cases in 
which these were present at the time of operation. It was 
especially valuable in cases subjected to vaginal section 
for the relief of sterility. The author reported several in- 
structive cases to substantiate the pointsmadeinhis paper. 
The Implantation of the Human Ovum in the Uterus. — 
Dr. Charles Sedgwick Minot of Boston discussed this 
subject by request. He stated that the human ovum 
produced upon its exterior during its earliest stages of 
development a thick layer of cells, the trophoblast. The 
function of the trophoblast was to corrode away a portion 
of the mucous membrane of the uterus, making a cavity 
in which the ovum lodged itself. The trophoblast there- 
upon underwent a hypertrophic degeneration, such as to 
produce a series of irregular spaces, which persisted and 
became the intervillous spaces of the placenta. Papillary 
outgrowths of the chorionic mesodenn meanwhile pene- 
trated the trophoblast, initiating the formation of the 
chorionic viUi. The trophoblastic cells over each meso- 
dermic outgrowth persisted in two layers, the inner cellu- 
lar, and the outer syncytial. These two layers repre- 
sented the first stage of the villus ectoderm. Similar 
observations had been made upon primates, and were com- 
pared with those upon the human subject. He compared 
briefly the method of implantation in man with that 
in other animals, to show that the trophoblast was of 
general occurrence, and that by destroying uterine tissues 
it inaugurated the formation of the true chorionic placenta. 
Bathing During the Menstrual Period. — Dr. J. Clifton 
Edgar of Xew York said that in the consideration of this 
subject several questions suggested themselves, namely, 
first, the advisability of bathing of any description during 
the menstrual period, and if at all, to what extent. Second, 
the use of the bath in dysmenorrhoea. Third, the use of 
Nauheim or other chemical baths or hydriatic procedures. 
Fourth, the risk of infection of the endometrium in in- 
tramenstrual tub-bathing. Fifth, the influence of modem 
athletics on women, lessening the risk, if any, of intra- 
menstrual bathing. These questions were submitted to 
the members of the society, from whom he had received 
one hundred and twenty- two acknowledgments. From 
the replies received, and the literature on the subject, 
he drew the following conclusions: " (i) All forms of 
bathing during the menstrual period are largely a matter 
of habit, and usually can be acquired by cautious and 
gentle progression, but not for every woman does this 
hold good, and surf bathing, where the body surface 
remains chilled for some time, should always be excepted. 
(2) A daily tepid sponge bath (85° to 92° F.) during the 
menstrual period is not only a harmless proceeding, 
but is demanded by the rules of hygiene. (3) In the 
majority of, if not all, women, tepid (85° to q2° F.) sponge- 
bathing after the establishment of the menstrual flow, 
namely, second or third day, is a perfectly safe practice. 
(4) Furthermore, in most women the habit of using the 
tepid shower or tub bath after the first day or two of the 
flow can with safety be acquired." 

The Streptococcus in Gynecological Surgery. — Dr. 
Hunter Robb of Cleveland. Ohio, stated that in order 
to arrive at some definite conclusions with reference to 
the streptococcus pyogenes as a cause of death in his 



work, he had made an analysis of all his cases in which 
this organism had been found during the past six years. 
It was shown from observations that quite a large niunber 
of liis patients died, and several were unimproved. It 
was also noticed that in the great majority of cases in 
which this organism was met with, there was a previous 
history of infection following labor, or an induced criminal 
abortion. In the past six years he had had 137 cases 
of abortion (.including a few cases of labor), in which 
it was necessary to carry out some form of treatment. 
Of this number, 104, or 75.9 per cent., recovered; 17, or 12.4 
per cent., were improved ; i , or .8 per cent., was unimproved . 
and 15, or 10.9 percent., died. In 16 of the 137 cases the 
streptococcus was found. The total number of all his 
cases in which the streptoccocus was found was 40, con- 
sequently those in which this organism was found following 
an abortion or labor formed 40 per cent, of the total 
number of streptococcus cases from every source. Of 
these, 16 patients (streptococcus cases), following abortion 
or labor, 4, or 25 percent., recovered; 3, or 18.75 percent., 
were improved; 9, or 56.25 per cent., died. In the whole, 
40 cases from every source, in which the streptococcus 
was foimd, the results were as follows: Recovered, 20, 
or 50 per cent.; improved, 6, or 15 per cent.; deaths, 
14, or 35 per cent. The streptococcus was found in the 
following combinations, given in order of frequency: 
(i) Streptococcus alone; (2) streptococcus and staphy- 
lococcus pyogenes aureus; (3) streptococcus, staphy- 
lococcus aureus, and bacillus coli communis. In all 
these cases, except three, in which they were obtained 
from the vagina, the organisms were obtained from the 
titerus, the adnexa, the cul-de-sac, or from several of 
these situations. In other words, they were proved 
to be present in places which were admittedly not their 
normal habitat. In the past five years he had had 724 
abdominal sections, with a total number of 32 deaths, 
or 4.43 per cent. In 7, or 21.9 per cent., of them the 
streptococcus pyogenes was demonstrated. In all there 
were 19 cases of abdominal operations in which the strep- 
tococcus was found. Of this number, 12 recovered, or 
63.2 per cent.; and 7 died, a mortalit)' of 36. S per cent. 

Indications for Operation for Fibroid Tumors of the 
Uterus. — Dr. Charles P. Noble of Philadelphia pre- 
sented a table of the degenerations and complications in 
a series of 1,188 cases of fibroid tiimors operated upon 
by Martin, Noble, Cullingworth, Frederick, Scharlieb, and 
in a series reported by Htmnerand MacDonald. Especial 
attention was called to the relative frequency of adeno- 
carcinoma of the uterus as compared with epithelioma 
of the cervix. The deduction drawn from this fact was 
that fibroid tumors were a direct predisposing cause of 
cancer of the cervix. A careful consideration of the 
facts presented in the table, said the author, should con- 
vince anyone with an open mind that the classical teach- 
ings concerning fibroid tumors were erroneous. This 
teaching was that fibroid tumors of the uterus were 
benign growths, which usually produced but few symp- 
toms, and which after the menopause underwent re- 
trogressive changes, becoming smaller or disappearing; 
that the chief danger of fibroid tumors consisted in the 
fact that at times they caused hemorrhage from the 
uterus, and that rarely they caused trouble, because of 
their size or because of pressure on adjacent viscera. An 
analysis of the 1,188 cases showed that because of the 
degenerations in the tumors, about 16 per cent, of the 
women would have died without operation; about 18 
per cent, would have died from the complications present. 
In addition, it was well-known that a certain percentage 
would have died from intercurrent diseases brought 
about by the chronic anaemia present in many of these 
cases, and by injurious pressure from the tumors upon 
the alimentary canal and urinary organs. In brief, at 
least one-third of the women having fibroid tumors, as 
shown by the author's table, would have died had they 
not been submitted to operation. 



I20 



MEDICAL RFXORD. 



[July i6, 1904 



The Treatment of Gonorrhoea. — Dr. Henry T. Bypord 
of Chicago said there was dissatisfaction with prev- 
alent methods of treating this disease. The desidera- 
tum was a local remedy that would rapidly destroy or 
remove the germs without injuring the protective epithe- 
lium, and a method of application that could be used by 
the patient which would not carry the germs to a deeper 
portion of the genitourinary tract. He advocated 
prolonged irrigations with hot water as a basis, and 
spoke of frequent injections of hot water as a substitute 
for prolonged irrigations. He detailed his experience 
with urethritis in the male, and referred to hydrogen 
dioxide and unirritating germicidal solutions as sub- 
stitutes for plain water injections, and gave their ap- 
plication to gonorrhoea in the female. The advantages of 
this treatment, when used early, were summarized by him 
as follows: "(i) It prevents the spread of the disease to 
adjacent parts. (2) It does not injure the epithelial cover- 
ing, and tends to limit the infection to the superficial 
areas. (3) It removes more germs and pus cells than either 
astringents or disinfectants can destroy. It acts in the 
same way as constant irrigation, both in aborting and 
arresting the progress of the infection. (4) It can be 
used more frequently than astringents or strong ger- 
micides, so that the parts can practically be kept free 
from pus and germs all of the time, while the method 
of using germicides or astringents three or four times 
daily allows the germs and pus to accumulate and spread 
between injections. (5) In the male, and possibly in 
the female, peroxide injections may be substituted when 
the time and facilities for the hot water treatment cannot 
be had. When the discharge has become scanty and the 
injections cannot readily be used so frequently, a. non- 
irritating solution of a silver salt can follow each hot 
water or peroxide treatment. (6) It may be used in 
connection with other injections for the dissolving of 
germs and culture material not eliminated by the douches. 
(7) It does no harm. It can be combined with the 
internal or local medication when it becomes impossible 
to carry it out with the necessary time-consuming 
detail It exemplifies the superiority of asepsis to anti- 
sepsis." 

Dr. Philander A. Harris of Paterson, N. J., exhibited 
and described a new uterine obstetrical dilator. 

OflScers. — The following officers were elected: President, 
Dr. E. C. Dudley, Chicago, 111.; Vice-Presidents, Drs. 
Henry D. Fry, Washington, D. C, and Henry C. Coe, 
New York; Secretary, Dr. J. Riddle GofFe, New York; 
Treasurer, Dr. J. M. Baldy, Philadelphia. 

Niagara Falls, N. Y., was selected as the place for 
holding the next annual meeting, in May, 1905. 



Treatment of Tabes. — O. Zicmssen discusses his method 
of handling this disease, which he bases on the assumption 
that the cord lesions are due to a disturbance in the 
capillary system, and that when the latter is righted the 
diseased tissues are regenerated. It is necessary to dis- 
tingxiish between the less prominent elementary disease 
and the secondar\' effects, which are a source of greater 
annoyance. Different remedies may be directed against 
one of these factors without in any way influencing the 
other. Ziemssen first places the patient on a thorough 
mercurial treatment, and unless this is carried out dili- 
gently the result is always failure. The method to he pre- 
ferred is by inunctions. In addition to this the amount 
of fluids is restricted, as in other circulatory diseases, 
and special measures are directed against the secondary 
manifestations, such as the ataxia, incontinence, neuralgia, 
etc. Even where the tabes has closely followed upon a 
traxima, the author has used the inunctions and later found 
that the patients had had syphilis. It is essential in 
every instance to begin treatment as early as possible, for 
as a rule the disease has existed for some time before the 
patient prc-^nts himself for examination. — Wiener klinisch- 
Iherapeuiisclie Wocheiischrift. 



Contagious Diseases — Weekly Statement. — Report of 
cases and deaths from contagious diseases reported to 
the Sanitary Bureau, Health Department, New York 
City, for the week ending July g, 1904: 



Ueasles 

Diphtheria and croup 

Scarlet fever , 

Smallpox 

Varicella 

Tuberculosis 

fypboid fever 

Cerebrospinal meningitis 



Cases. 



Deaths. 



261 


15 


297 


29 


95 


»3 


I 




29 




359 


136 


39 


9 




34 



An Unusual Form of Influenza. — J Latkowski reports 
a localized epidemic disease characterized by a sudden 
invasion, chills and fever, swelling of the eyelids, muscular 
pains, and general prostration. Examination of the 
secretion from the conjunctiva showed the presence of 
the influenza bacillus. This swelling of the lids is an 
unusual phenomenon, and the author believes that the 
connective tissue forms the portal of entree for the germs, 
from which they are distributee! through the body. — 
Wiener klinisch-iherapeutische Wochenschrift. 

Health Report. — The following cases of smallpox, 
yellow fever, cholera, and plague have been reported 
to the Surgeon-General, U. S. Marine Hospital Service, 
during the week ended July 9, 1904: 



SMALLPOX UNITED STATES. 



Delaware, Wilmington June 

District of Columbia, Washington .June 

Florida, at large June 

Georgia, Macon June 

Illinois, Belleville June 

Chicai^o June 

Danville June 

Kentucky. Co\*ington June 

Louisiana, New Orleans June 

Maine, Madawaska Region June 

Michigan, Detroit June 

At 88 localities June 

Missouri, St. L#ouis June 

Nebraska, Omaha June 

New Hampshire, Manchester June 

New York, New York June 

Ohio, Dayton June 

Pennsylvania, Altoona June 

Philadelphia June 

Steelton June 

Tennessee, Memphis June 

Nashville June 



2s-July 2. 

iS-25 

18-25 

3S-July 2 

1-30 

2 5 -July 2 
2 5 -July a 
2S-July 2 
2«;-Julv 2 

18-25 -■ 

14-21 

i8-2S 

25-July 2 
25-July 2 
25-July 2 
2 5- Jul V 2 
1 8- July 2 
25-july 2 
July 2 
July 2 
-July 3 
July 2 



CASES. DEATHS. 



18 



Present 



25- 
25 

25- 
25 



SMALLPOX FOREIGN. 

.\ustria, Prague June ii-i8 

France, Paris June 1 1-18 

Great Britain, Bradford June 4-18 

Bristol June 11-25 

Cardiff June 4-1 1 

Edinburgh. ' June 4-1 1 

Glasgow June 17-34 

Liverpool June ii-iS 

London Tunc 11-18 

Manchester June 4-18 

New-Castle-on-Tyne June 1 1-18 

South Shields June 11-18 

India, Bombay May 31-lune 7 . 

Calcutta May 2S-June 4 . 

Karachi May 29-June 5 . 

Panama. Panama June 12-19 

Russia, Moscow June 4-1 1 

St. Petersburg June 4-18 

Warsaw May 14-21 

Warsaw^ May 28-June 4 • 

Spain, Barcelona May 20-June ao. 

Turkey, Alexandretta June 4-11 

Beirut May 28-June 4 . 

Constantinople June 12-19 



IS 
6 



24 

27 



Present 



YELLOW PEVBR. 

Ecuador. Guayaquil May 3 5- June 8 is 

Mexico, Merida June 12-18 7 > 

Vera Cruz June 18-25 * ' 

Panama, Panama June 1 2-19 1 

PLAGl'E. 

Africa, Johannesburg Apr. i i-May t . . . . 2 3 

Australia, Brisbane May 3-2 1 7 2 

Sydnev May 14-21 i 

E^ypt May 21-28 ao 10 

includint: Alexandria, i case, i death; Port Said, i case. 1 death. 

India, Bombay May 3t-June 7 78 

Calcutta May 28-June 4 7° 

Karachi May ag-June 5 ■ • • 3© 30 

Peru. Payta May 29-June 4 ... 1 1 7 

CHOLERA. 

India. Calcutta May 28-June 4 24 

Madras May 28-June 3 a 

Turkey, Bahrein Ulands; Miy 10 Epidemic. 



Medical Record 

A Weekly Journal of Medicine and Surgery 



Vol. 66, No. 4. 
Whole No. 1759. 



New York, July 23, 1904. 



$5.00 Per Annum. 
Single Q>pies, 10c. 



(Original ArtirlpH. 



NOTES ON SOME UNCOMMON FORMS OF 
NERVOUS DISEASES.* 

Bt L. pierce CLARK, M.D., 

NEW YORK. 

VISITING NEUROLOGIST TO THE RANDALL'S ISLAND HOSPITAL AND 
schools; consulting NEUROLOGIST TO THE MANH.\TTAN STATE 
HOSPITAL. NEW YORK. 

I DESIRE to place on record the following short 
abstracts of some uncommon forms of nervous dis- 
ease in patients that have presented themselves at 
the Vanderbilt Clinic during the past two years. 
I am much indebted to Dr. Starr for his kind per- 
mission to publish the cases; 

Multiple Neuritis with Intact Reflexes. — Case I — 
J. S.. five vears old, whose case is incorporated 
in this report by kindness of Dr. Hart, is an imbecile 
and possibly epileptic. He was born at term with 
instruments after a prolonged dry labor of eighteen 
hours. He was much asphyxiated, but no con- 
viilsions were reported. There were scrofulous 
suppurating glands of the neck at six months. 
He only began to talk at three years of age. July, 
1902, he suffered from what the family supposed 
was gastritis, but which was probably lead colic ; 
he recovered entirely, and was well for two weeks, 
until September 15, 1902, when it was noticed one 
morning that he was lame in both feet and there 
was bilateral foot-drop. Two months after his 
hands became affected in the same manner, show- 
ing the characteristic wrist-drop of lead palsy. He 
handled lead during the two weeks after recovery 
from the illness in the summer and again in Sep- 
tember. The relatives believe his taking strong 
medicine during the summer had something to do 
with it, but this seems improbable from the history 
of treatment. At present he is in the recovery 
stage of multiple neuritis, apparently of lead 
origin. All reflexes are exaggerated; no sensory 
changes. Great diminution of faradic and galvanic 
current, but no qualitative change. 

In multiple neuritis the reflex action in the 
muscles is almost invariably lost (Gowers , but in 
rare cases, such as those reported by Dejerine, it 
may persist. Its retention, however, is exceptional, 
and probabl)' depends on the escape of at least some 
of the fibers on which the action depends. The 
retention of the knee-jerk throughout the entire 
course of the disease cannot be explained on the 
basis that they are sometimes excessive in the early 
stages of the disease (in consequence of an irritable 
state of the nerves on which they depend) similar 
to that which gives rise to hyperassthesia. On the 
the other hand, usually in the slightest grades of 
neuritis the reflexes are lost, however muscle ten- 
derness is almost invariably present, indicating an 
involvement of the afferent sensory nerves. 

Myoclonus. — Case II — B. S., eleven years old, 
Jewish. Two years ago, without rheumatism, heart 
disease, or fright or other known causes, a lightning- 
like clonic spasm developed in the left biceps, 

*Read before the .Academy of Medicine, Section on 
General Medicine, Ma v 17, 1904. 



triceps, pectoralis major, latissimus dorsi and 
sternomastoid, and in a few weeks the same muscle 
of the right arm also became involved. The spasm 
was then as now nearly bilateral, lightning-like, and 
clonic in character, occurring twenty to forty times 
a minute. There were good and bad days, but 
there was never more than a few minutes of entire 
freedom from the spasm. In a few months the 
muscles of the pelvic girdle became involved, par- 
ticularly the glutei, quadriceps, the adductors, and 
the sartoriis. He had no difficulty in swallowing; 
there was, however, a diaphragmatic grunt. He 
cannot inhibit the morbid movements now as long 
as formerly. Of late the supinators of the forearms 
and peroneal group in the legs have been occasion- 
ally involved. No spasm in fingers or toes have 
ever been observed, although of late infrequent 
facial spasms have occurred. The muscles in- 
volved first in the disease are now involved most. 
Musculature is good ; no atrophy ; no sensory changes ; 
all reflexes are normal. There is marked disturb- 
ance in writing. He inhibits the spasms while 
writing single words, and then in the frequent 
pauses the "jerks" are intense. The worst sample 
given here was on one of the patient's "bad days," 
when the uninhibited spasms were so sudden and 
brisk as to make "rockets" before the hand could 
be voluntarily withdrawn from the paper in the act 
of writing. 

The illustrations on the following page are copies 
of the handwriting in this case of myoclonus: (For 
similar specimens see the report of the author's 
cases inthe Archives of Neurology and Psychopathology, 
Vol. 2, Nos. 3-4, 1899.) 

Cases of myoclonus, although not rare, are still 
uncommon. In diagnosticating the affection we 
permit a wider latitude in the disease complex than 
formerly. Although the essentials of the affection 
are usually held to embrace the symptom of bilateral 
clonic lightning-like muscular spasm involving 
proximal muscles most or exclusively, cases are un- 
doubtedhr reported in which one or more of these so- 
called essentials are very much modified or absent. 
It is intere.sting to note in France, where the tics 
have been most thoroughly studied, that the names 
of "multiple tics" and "electric chorea" (Henoch- 
Bergeron's disease) still do service for many ob- 
viously well-marked cases of myoclonus. Even 
in this country myokymic (Schultze) as well as 
multiple tics and electric chorea are frequent designa- 
tions for myoclonus. In Russia also Koschewniskow's 
epilepsy can hardly be other than myoclonus- 
epilepsy. Bechterew also reports from time to time 
altogether too many cases of choreic epilepsy. The 
latter is an extremely rare association in the experi- 
ence of most neurologists. We believe, as 
Oppenheim holds, that these peculiar tics and 
choreas should be arranged under the head of 
myoclonus. It will then be possible for us prop- 
erly to classify the different types of the affection. 
An ambitious attempt in this direction has alreadv 
been undertaken by Dana in the Journal of Nervous 
and Menial Diseases, June, 1903. 



122 MEDICAL RECORD. [July 23, 1904 

Paradoxical Pseudohypertr